TCNJ Testing

TCNJ COVID Testing Registration
Event
PassStatus
This form acts as your registration for your COVID test at TCNJ by New Bridge Medical Center. Please have all forms of identification listed below available when completing the questions.
- TCNJ Student ID Card and associated TCNJ email (xxxxx@TCNJ.EDU)
- Government Issued ID (Drivers License, Passport or State Issued ID)
- Vaccination card (COVID vaccination)
- Health insurance information/card
Once your form is submitted you will receive a QR code to your TCNJ.EDU email account. Please use this code to check in for covid testing.

NEED HELP?

Please direct all of your questions to covidquestions@newbridgehealth.com via email

DEMOGRAPHIC INFORMATION
First Name *
Middle Name
Last Name *
TCNJ PAWS ID or Employee ID Number
Upload TCNJ PAWS or Employee ID

Cancel of
TCNJ Email Address Validation *
example@tcnj.edu
Mobile Number (Test Results will be text to this number) *
Please enter a valid mobile phone number for SMS messages
Confirm Mobile Number
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Biological Gender *
Date of Birth (DOB) *

Month Day Year
Date

IDENTIFICATION VALIDATION:

Picture of a government issued ID, e.g. Driver's License, Passport and/or State ID is required for testing services. For minors (under 18 years of age), please upload parent/guardian identification.

UPLOAD PICTURE ID: Click take picture and use your phone or computer camera to snap photo or upload from a saved picture
Upload Picture Drivers's License or Government ID *

Cancel of
HEALTH INSURANCE INFORMATION

Please provide the following information for the Primary Member/ Policy Holder on the Insurance account.
Do you have insurance? *
Insurance Company
Primary Member/Policy Holder Full Name *
Primary Member/Policy Holder Date of Birth (DOB) *

Month Day Year
Date
Patient relationship to Primary Member/Policy Holder?
Member/Subscriber ID *
Group/Policy Number *
Upload Photo of the Front Side of your Insurance Card *

Cancel of
Upload Photo of the Back Side of your Insurance Card *

Cancel of
VACCINATION VALIDATION
Vaccinated for COVID-19? *

CLINICAL QUESTIONS
Is this your first COVID test? *
Are you symptomatic, e.g. flu like symptoms? *
Are you pregnant? *

This is to certify that I am requesting to be tested for COVID-19. I understand the importance of knowing if I had a current or previous infection.

CONSENT STATEMENT

I agree to have Bergen New Bridge Medical Center Laboratory (“BNBMC Laboratory”) collect either a nasal or saliva sample to test for COVID-19. I understand that I may have some minor discomfort or slight bleeding at the site when the nasal swab is collected. Furthermore, I agree to have a copy of my results sent to an appointed representative at The College of New Jersey (“TCNJ”). I understand that TCNJ may disclose the results to governmental health authorities and use the results to perform contact tracing, and ensure compliance with the TCNJ Health and Safety Policy and other applicable TCNJ policies and I hereby consent to such disclosure and use.

I agree to the following;

I am not currently symptomatic
I consent to the sample collection for myself and billing to my insurance company

I agree to let BNBMC Laboratory take my samples and release the information to TCNJ. I am aware that the practice of medicine is not an exact science and results cannot always be anticipated. I acknowledge that no guarantees have been made to me concerning the results of COVID-19.

I understand that Navus Health, LLC (“Navus”) is not a health care provider, and is assisting the Lab in collecting the specimen from me for COVID−19 testing and in reporting my COVID-19 test results. To the fullest extent permitted by law, I hereby release, discharge and hold harmless, Navus and its respective members, managers, oﬃcers, employees, representatives and agents, from any and all claims, liabilities, losses and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to the collection and submission of my COVID-19 test or the disclosure of my COVID-19 test results as permitted by law.

This consent extends not only to the BNBMC Laboratory and doctors and other health care providers to whom I have entrusted my care and others with or designated by them, but also to the Bergen New Bridge Medical Center and representatives.

I have read and understood the above information or had it read to me, and had all of my questions answered to my satisfaction. I am of sound mind and body. If I am not 18 years of age or older, my parent or guardian has also signed below.
PLEASE SIGN (Signed agreement available upon request) *

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TCNJ COVID Testing Registration

This form acts as your registration for your COVID test at TCNJ by New Bridge Medical Center. Please have all forms of identification listed below available when completing the questions.

Once your form is submitted you will receive a QR code to your TCNJ.EDU email account. Please use this code to check in for covid testing.

NEED HELP?

Please direct all of your questions to covidquestions@newbridgehealth.com via email