Phone: (805) 756-1211
Fax:     (805) 756-5298

8:30 AM - 4:30 PM | M-F
Building 27


Google Translate


Please find the available forms below. A copy of a current picture identification, including signature (i.e. driver's license, passport) must be included with requests to release PHI or exchange PHI with parents/guardians.


Parents/legal guardians giving consent for medical treatment of their minor

Minor - Verification of Emancipation

Patients under the age of 18 declaring emancipation

Medical Exemption Policy for Required Vaccinations

Policy outlining the criteria and the process for exemptions to immunization requirements based on a medical condition

Medical Exemption Request Form

Form to be submitted for requesting a medical exemption for required vaccinations based on a medical condition

Religious/Personal Belief Exemption Policy and Request Form for Required Vaccines

Policy outlining criteria and process; form to be submitted for requesting an religious/personal belief exemption for required vaccinations

Medical Records Release Form

To request health information from past visits

Authorization for Disclosure of Protected Health Information to Parents/Guardians

Allow parents/guardians access to student health records

Notice of Privacy Practices (PDF)

This notice describes how medical information about you may be used and disclosed, and how you can get access to your information

No Show/Late Cancellation Fee Appeal Form

Request fee cancelation because of extenuating circumstances or an error

Request for Interview Form

Request interview from Campus Health & Wellbeing

Patient Rights & Responsibilities

For patient review only
For students getting a COVID-19 vaccine at Campus Health & Wellbeing

Health Center Portal

The Health History form needs to be filled out prior to your first visit at the Health Center.

Related Content

About Us

Contact Us

In Solidarity

In Solidarity

Meet the Staff

Meet the Staff