The forms below are the ones students must complete
on their first visit to the Student Health Center.
All forms are in PDF file format.
New Intake Forms (student has not been seen or use the SHC pharmacy
within the last three years)
- Student Financial Agreement
- Student Wellness Consent
- The Notice of Privacy Practices: Effective April 14, 2003 we must provide a copy to all students and document
that a copy was given to them by signing an acknowledgment for receipt of this form. Student signs this form when he/she checks in at the SHC.
Request for patient health information (PHI)
** Information regarding procedure to request PHI - Any student who requests a copy (ies) of his/her health records must complete, sign and submit an authorization form to the Student Wellness Center. There is a charge of $.60 per page payable at the time the copies are available for pick up.
Authorization to
request health records
Immunizations
If the visit to the Student Health Center is for Immunizations (vaccines), new students must also complete the New Intake
Forms in addition
to this form: Immunizations
Questionnaire and Vaccination form (i.e. MMR, Td,
Flu vaccine, Hepatitis B, Hep. A & B)
TB PPD Skin Test Screening
form Students may want to complete these forms before coming
to the SHC if they have an appointment for for a vaccine or TB skin
test.
Information about Lab Exiting Procedures
This information to help students understand the process to
get lab results and how long does it take to get results back.
Authorization for Release
of Patient Prescribed Medication
Students who are not able to pick up their prescription, may complete
the following form to have someone else pick up the prescribed medication.
