Creating the Extraordinary Student Experience

Forms

All signatures on forms must be completed manually.  Electronic signatures are not accepted.

All of the forms below can be completed online and then printed.  When completing by hand, please use black ink.  This allows for a clearer image when scanned.

Absence Excuse (PDF)
This form can be used to explain an absence from class due to illness.
 
Allergy Injection Consent (PDF)
Informed consent for administration of allergen immunotherapy.
 
Allergy Referral Guidelines (PDF)
Instructions for new patients or patients who are to be retested.
 
Administration of Allergen Immunotherapy (PDF)
The completion of this form by the patient's doctor/allergist is required before allergy injections can be given at the Wilce Student Health Center.
 
Animal/Biological Agents Contact and Use (PDF)
Complete this form to provide your individual health history to Preventive Medicine.
 
Annual Tuberculosis Evaluation (PDF)
Complete this form if you have a reported history of a positive TB skin test.
 
Food and Activity Log (PDF)
Complete this form prior to your first nutrition appointment.
 
Insurance Third Party Registration Form (PDF)
Complete this form prior to your first appointment if you have third party insurance or if your insurance information changes.
 
Insurance Out of Network Notice (PDF)
This notice is given to patients with third party insurance for whom SHS is out of network.
 
Medical Records Release Authorization (PDF)
Complete this form to give permission to have your records released to the specified individual/business.
 
Medical & Dental History (PDF)
All patients are asked to complete both sides of this form, including signature, prior to their first appointment at the Wilce Student Health Center.
 
Motor Vehicle Accident Information (PDF)
Complete this form is you have been injured in a motor vehicle accident.
 
MyBuckMD Consent Form(PDF)
Complete this form and present to the Patient Registration Desk on the first floor to enable your access to MyBuckMD.
 
Notice of Privacy Practices Acknowledgement (PDF)
Complete this form to acknowledge you have received information on the SHS privacy practices.
 
Nutrition Questionaire (PDF)
Complete this form prior to your first nutrition appointment.
 
Personal Pocket Medical History (PDF)
This form can be used to keep track of your personal medical history.
 
Pharmacy Dependent Access (PDF)
Complete this form to register your dependent(s) so they can fill prescriptions at the Student Health Center Pharmacy.
 
Physican Information Sheet (PDF)
Information for physicians regarding allergy and other injections given at the Wilce Student Health Center.
 
Referral Scheduling Form (PDF)
Complete this form to provide the Referral Coordinator with all pertinent informaion for scheduling your appointment with a specialist.