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Greenwich CountryDay School
Faculty Patient Registration

We need to collect a few details before we can begin testing.

This information is collected to send results to you directly through our patient portal. Be sure to enter all information accurately to receive your results quickly.

 

This form is secure and HIPAA-compliant .

Patient In-Take Form
Personal Information:
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Testing Program:
Are you an employee, staff, or faculty?
Choose a test collection method:
Medical Information:
Are you experiencing any flu like symptoms?
Do you have any medical conditions?
Do you take any medications?
COVID-19 Information:
Have you previously tested positive for COVID-19?
Do you suspect you've been exposed to COVID-19 directly or indirectly?
Insurance Information:
Do you have insurance?
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Driver's License / Insurance Card:
Upload File
(Max 15MB)
Upload File
(Max 15MB)
Upload File
(Max 15MB)
Sign and Submit:

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On-Site testing solutions and strategies.

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