COVID 19 Form

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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

  • MM slash DD slash YYYY
  • Test Details

  • MM slash DD slash YYYY
  • Employer Information

  • School Information

  • (Teacher/ Student/ Other)

*For Tele Visits you should have a Smartphone or Computer with a Camera plus microphone ready.

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