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

Phone Hours
8:30 AM - 5:00 PM | M-F
9:00 AM - 5:00 PM | W

In Person Hours
8:30 AM - 4:30 PM | M-F
9:00 AM - 4:30 PM | W

Building 27




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 Use

Consent Form for Medical Treatment of Minors (PDF)


Minor - Verification of Emancipation

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


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 (PDF)


Hepatitis B and Measles/Rubella Immunization Form (PDF)

To request health information from past visits.



Instructions/directions for submitting CSU required immunizations.

X-ray Release Form (PDF)

To request x-rays taken prior to September 2010.

Authorization for Disclosure of Protected Health Information to Parents/Guardians (PDF) 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 Use this form to appeal a no show or late cancellation fee.
Request for Interview Form To request a media or other interview with our staff.
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.

Related Content

About Us

  • Location

    Building 27 - Health Center

  • Phone

    24/7 Support
    Health: 805.756.1211
    Counseling: 805.756.2511
    Wellbeing: 805.756.6181
    Safer: 805.756.2282

  • Hours

    Mon-Fri: 8:30 AM - 4:30 PM;
    Wed 9 AM - 4:30 PM

Contact Us


Call for appointment

In Solidarity

More information

Meet the Staff

Meet the Staff