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COVID 19 Form

In order to comply with Executive Order (EO) 202.61 issued by Governor Andrew M. Cuomo we have to collect this information for people testing for COVID-19

If you would like to read further on the Executive order use the link below-
Executive Order (EO) 202.61

Covid-19 Form

Name
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Test Details
First Test?*
- Yes
- No
Healthcare Employed?*
- Yes
- No
Hospitalized?*
- Yes
- No
Admitted to ICU?*
- Yes
- No
Congregate care?*
- Yes
- No
Symptomatic?*
- Yes
- No
Symptom onset date:
Date Format: MM slash DD slash YYYY
Employer Information
Employer Name
Employer Address
Street Address City State / Province / Region ZIP / Postal Code
Employer Phone Number
School Information
School Name
School District
School District
School Job:
(Teacher/ Student/ Other)
Was the patient at school in the past 7 days?
- Yes
- No
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*For Tele Visits you should have a Smartphone or Computer with a Camera plus microphone ready.

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This information is not intended to replace the advice of a physician. Always seek the advice of a physician or other qualified healthcare provider for treatment and advice. If you believe you are experiencing a medical emergency, call 911.

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MD 365
800 Montauk Highway, Suite 18
Shirley, New York 11967

631-772-4646

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COVID 19 Form

Covid-19 Form

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School Information

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