Forms

Forms



For your convenience, the following forms are available online to shorten your wait time at the health center.If you are coming to the health center for the first time, please print the health history form and have it filled out by the time you come for your appointment.

 

If you are coming for an immunization or TB skin test, please choose the corresponding consent form to print, fill out and bring with you to your appointment.

 

If you wish to obtain a copy of your immunization records or any part of your current medical file, please print the Immunization and Medical Record Release Form and fill it out. This form can be faxed to us. FAXED forms are free. If you wish to receive these records in hand or have them mailed to you, it will cost $5.00. You can pay for this at the Controller’s Office and bring us a receipt or have the $5.00 on your Lion’s Lagniappe card (student I.D.).

 

Available Forms:

 

1.    Health History Form

2.    Proof of Immunization Compliance Form

3.    Immunization and Medical Record Request Form

4.    Confidentiality & Consent Form

5.    Allergy Injection Consent Form

6.    Depo Consent Form

7.    Flu Vaccination Consent Form

8.    Hepatitis A Vaccination Consent Form

9.    Hepatitis B Vaccination Consent Form

10.  Men's Health Clinic

11.  Meningitis Vaccination Consent Form

12.  TDap Vaccination Consent Form

13.  TB Skin Test Consent Form

14.  Women's Health Clinic



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