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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.
A 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 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
COVID-19 Vaccination Consent and Questionnaire
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.
