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Required Immunization History Form

ALL new first-year, transfer, graduate, and international students must submit the ESF Immunization History Form.

Download Form

Immunization History Form (PDF)

Mail, Email or Fax

Email to:
ESFhealthservices@crousemed.com

Mail to:
Crouse Medical Practice
739 Irving Avenue
Suite 300, ESF Clinic
Syracuse NY 13210

FAX - 315-766-1614

Your Immunization History Form must be submitted by:

  • August 1 (for Fall admits)
  • January 2 (for Spring admits)

Per New York State law, we are required to collect this information.

Pursuant to NYS Public Health Law § 2167, all students regardless of age, must read and certify that they have been informed about meningitis.

Any student who believes they should be exempt from the immunization requirements must email Crouse Medical Practice at esfhealthservices@crousemed.com for further instructions before the deadline.

Failure to submit the ESF Immunization History Form by the identified deadline may result in a hold being placed on your account and having your classes cancelled.

Questions

If you have questions regarding your medical information, contact Crouse Medical Practice: 315-766-1628

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