Firefighters: Request a Screening

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Most of the firefighter screenings can be completed during the 2022 Firefighter Screening Day on Saturday, May 14, or you may be scheduled to complete the screenings on another day if that is convenient for you.

Complete the form below and a member of our team will call you to complete registration.

Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

Insurance Provider(Required)

Subscriber ID(Required)

To expedite your registration call, upload a photo or scan of your card.

Drop files here or

Max. file size: 2 MB.

Firefighter Status(Required)

Screening Services Scheduling Preference(Required)

I would like to attend 5/14 event, morning preferred

I would like to attend 5/14 event, afternoon preferred

I would like to attend 5/14 event, any time that day

I would like to schedule my screenings for an alternate date/time

My schedule is flexible

Do you have a Primary Care Provider? If so, list the name/practice below. If you do not have one, write 'none':

If you do not have a PCP and would like to establish with a provider, please contact navigator@crouse.org or call 315-470-8034.

Do you have a Cardiologist? If so, list the name/practice below. If you do not have one, write 'none':

If you are not currently a member of the YMCA, would you be interested in a FREE eight-week trial?

Yes

By selecting yes, you agree to have the information provided on this form shared with the Intake Coordinator at the YMCA.

YMCA Branch you would use most frequently:

The information you provide on this form will be shared with the screening providers including Crouse Medical Practice, Crouse Radiology Associates, and Hematology-Oncology Associates of CNY

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Firefighters: Request a Screening

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