A Consent Form for Medical Treatment of Minors (PDF)

Minor - Verification of Emancipation

Medical Exemption Policy for Required Vaccinations

Medical Exemption Request Form

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

Medical Records Release Form

To request health information from past visits. There are some requirements for this form: 

• This form must be printed and hand signed. Digital signatures are not accepted.

• Use only blue or black ink when filling out the form.

• If you make a mistake, cross it out and initial the correction.

• Each requested item must be initialed.

• Provide specific dates or a defined time period for the records requested (e.g., May 1, 2023 – June 30, 2023).

• Vague terms are not accepted, do not use "present" or "graduation" for dates.

• If an expiration date is included, it must allow at least 15 days for processing and be a specific date (e.g., June 7, 2023).

• Include a scanned copy of a government-issued ID, front and back, which contains a signature when submitting the form (i.e. driver’s license, passport).

• Submit the completed form by mail, fax, or email. If submitting by email, scan the completed form and a copy of your ID, then send them to health@calpoly.edu.

Authorization for Disclosure of Protected Health Information to Parents/Guardians

Notice of Privacy Practices (PDF)

No Show/Late Cancellation Fee Appeal Form

Request for Interview Form

Patient Rights & Responsibilities

COVID-19 Vaccination Consent and Questionnaire

Health Center Portal