51³Ô¹Ï

Please find a list of forms below that may be useful for you to become in compliance with your immunization and Health Record requirements at 51³Ô¹Ï.

Most commonly needed forms

• Meningitis Response and Information form (pdf)
• Release of Information (pdf) 
• General Student Health Record (pdf)
• Healthcare Student Medical History & Physical Report (pdf)
• Tuberculosis Screening (pdf)
• Cardiac Athletic Questionnaire (pdf)
• Immunization Form (pdf)
• Under 18 Permission to Treat (pdf)
• Consent for Treatment/Privacy Policy (pdf)

There are a variety of ways you can submit your paper work.

• Upload your documents directly to your patient portal by clicking . Log in using your single on. 
• Email to wellness@farmingdale.edu
• Drop off in person at the Health and Wellness Center.  If the office is closed, you can deposit your forms in a secure mailbox located at the front and rear entrances of the Health and Wellness building.
• Fax: (934) 420-2137
• Mail: to 51³Ô¹Ï- Attn: Health and Wellness Center, 2350 Broadhollow Road, Farmingdale, NY 11735.

Insurance Related Information

• As of 2020, 51³Ô¹Ï is no longer offering a school sponsored insurance plan.
• Visit for information on New York State offered insurance plans.

Important Links

• Student Immunization Policy (pdf)
• Patient Rights and Responsibilities (pdf)
• Measles, mumps, and rubella Vaccine Information Sheet (pdf)
• Tetanus-diphtheria Vaccine Information Sheet (pdf)
• Menactra (meningococcal) Vaccine Information Sheet (pdf)
• Seasonal Influenza Vaccine Information Sheet (pdf)
• Tobacco Use Policy