Info

Phone: (805) 756-1211
Fax:     (805) 756-5298
health@calpoly.edu

Hours
8:30 AM - 4:30 PM | M-F
Building 27

Forms

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Forms

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.

FORM/request Description
Consent Form for Medical Treatment of Minors (PDF) 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 Request Form Form to be submitted for requesting a medical exemption for required vaccinations based on a medical condition
Medical Exemption Policy for Required Vaccinations Policy outlining the criteria and the process for exemptions to immunization requirements based on a medical condition
Medical Records Release Form To request health information from past visits
Hepatitis B and Measles/Rubella Immunization Form Instructions/directions for submitting CSU required immunizations
X-ray Release Form To request x-rays taken prior to September 2010
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 cancellation because of extenuating circumstances or an error
Request for Interview Form Request interview from Campus Health & Wellbeing
Advance Health Care Directive Advance directives are legal documents that allow you to plan and make your own end-of-life wishes known in the event that you are unable to communicate
Patient Rights & Responsibilities For patient review only
Food Journal Journal for logging eating habits

Health History Form

  • The Health History form needs to be filled out prior to your first visit at the Health Center. This form is available in the Health Center Portal.

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