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Forms

Gannett Health Services
110 Ho Plaza
Cornell University
Ithaca, NY 14853-3101

Tel: 607 255-5155
Fax: 607 255-0269
Email

Please print out the necessary form(s). Then, complete all information in blue or black ink.

Release of health records; privacy practices

Health history forms

  • Faculty and Staff Health History (pdf)
    To be used only by Cornell University employees.
  • Report of Physical History (pdf)  
    If you are seeking a general physical exam, but do not have form to complete (e.g., for a potential employer, institution of higher education, etc.), use this form. 
  • Sports Clearance (directions and pdf)
    This form must be completed by all incoming students who have been recruited as intercollegiate athletes.
  • Travel Clinic History (pdf)
    If you filled this form out via myGannett, you do NOT need to fill out a paper copy.

Department charge authorization


Ithaca-area medical providers