Health History Form [PDF]
Fill out this form before your first appointment. Also available online through MyHealthSpace.
List of Forms
Some forms are also available online through MyHealthSpace, where noted.
Medical Release Form [PDF]
Complete this form to release certain health records to an outside doctor, insurance company or family member.
Permission to File Insurance [PDF]
Complete this form to file an insurance claim with your provider. Also available online though MyHealthSpace.
Immunization Form [PDF]
This form needs to be completed and on file with Student Health Services before your orientation to avoid a hold on your class registration. When you log in to MyHealthSpace, go to the “Forms” tab, enter your immunization information, fill out the form and after your doctor signs the form, please mail or fax it back to Student Health Services.
Notice of Privacy Practices [PDF]
Understand how your medical information is stored, who can access it and how it may be used or disclosed. Also available online through MyHealthSpace.
Treatment Agreement [PDF]
Complete this form to receive treatment recommended by Student Health Services health providers. Also available online through MyHealthSpace.
Pharmacy Transfer Form [PDF]
Fax this form to Student Health Services to transfer your prescriptions to or from another pharmacy.
Travel Clinic Questionnaire [PDF]
If you are planning to travel abroad, bring this completed form with you to your travel consultation with the Travel Clinic.