Health, Wellness and Recreation

Forms

The forms below are the ones students must complete on their first visit to the Student Health Center.  Returning patients will be asked to complete a self check-in process, update contact information, and complete an annual health history.

Intake Forms

(Student has not been seen or used the SHC pharmacy within the last three years.)

• Student Financial Agreement
• Student Wellness Consent
• The Notice of Privacy Practices

We must provide a copy of the aforemetioned documents to all students and document that a copy was given to them. Students will sign an acknowledgment for receipt of this form when he/she checks in at the SHC.

Immunizations

If your visit to the Student Health Center is for immunizations (vaccines), you will need to complete the intake forms listed above, in addition to the immunizations questionnaire and vaccination form below. (i.e. MMR, Td, Flu vaccine, Hepatitis B, Hep. A & B). If you are coming in for a TB (PPD) Skin Test, you will need to complete a screening form.

• Immunizations Questionnaire and Vaccination Form
• TB PPD Skin Test Screening Form

Additional Forms and Information

• Request for Patient Health Information (PHI)
• If you would like to request a copy of your health records, you will need to complete, sign and submit this form to the Student Wellness Center. There is a charge of $.60 per page.
• Voluntary Health Withdrawal Request Form