Covid-19 Contact Tracing Form
Please complete this form as per NYS Contact Tracing Protocol PRIOR TO YOUR SCHEDULED APPT AT SUNSHINE PHARMACY
Scheduling for Covid-19 Antibody IgG/IgM Test
This form schedules an exam for 1 individual per submission. If you are scheduling for multiple individuals you may schedule up to 4 appointments per time slot.
Covid 19 Rapid IgG/IgM Antibody Test
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NYS Contact Tracing Information
Please complete all fields as required per NYS Protocol
Patient First Name
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Patient Last Name
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Patient Middle Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
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Next
Patient Demographics
Please complete all fields as required per NYS Protocol
Patient Date of birth (MM/DD/YYYY)
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Patient Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Age
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Gender
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Male
Female
Other
Ethnicity
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Please Select
Hispanic
Non-Hispanic
Race
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American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White
Unknown
Other
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Employer or School information
Please complete all information as required per NYS reporting protocol
Is the patient currently employed or in school?
Yes
No
Employer or School Name
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Employer or School Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Was the patient at work or school in the last 7 days?
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Yes
No
N/A
Employer or School Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
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Patient Medical Information
Please complete all information as required per NYS reporting protocol
Primary Care Physician
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Primary Care Physician Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Is this the patient's first COVID-19 Test?
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Yes
No
Does the patient have any underlying medical conditions?
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Yes
No
Are you currently exhibiting symptoms of COVID-19?
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Yes
No
If yes, what date did the symptoms start?
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 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you experiencing any of the following symptoms, possibly due to the COVID-19 virus?
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Fever
Cough
Sore Throat
Congestion
Body Aches
Runny Nose
Loss of taste and/or smell
None
Have you come in contact with someone with confirmed COVID-19?
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Yes
No
Are you employed in the healthcare field?
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Yes
No
Have you been recently hospitalized?
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Yes
No
Have you recently been in an ICU?
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Yes
No
Have you recently been in a congregate care setting?
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Yes
No
Have you traveled domestically in the last 2 weeks?
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Yes
No
Have you traveled internationally in the last 2 weeks?
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Yes
No
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I understand that my personal information and test results will be shared with NYS Dept. of Health.
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Yes
I understand that negative test results could be false negative and that I should confirm the negative results with another lab analyzed high complexity test
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Yes
I consent to being tested and that I confirm that I am at least 18 years of age or signing for minor under the age of 18
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Yes
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Submit
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