Forms

Following are forms the Health Center will need prior to being seen by any of its providers. Please download the forms you need, fill out, and bring to your first appointment.

Forms Needed for All Office Visits

Form / Document Title	Format	Format
Authorization to Obtain/Release Medical Information	Word
Consent for Treatment	Word
HIPAA Overview	Word
Medical History	Word
Minor Consent for Treatment	Word
Family Pact Application	Word

Additional Forms Needed for Gynecology Appointments

Form / Document Title	Format	Format
Contraceptive Consent Form	Word
Gynecology Medical History	Word
Depo Provera Calendar (calculates dates)	Excel
Using Contraceptives Successfully	Word
What You Should Know About Contraceptives	Word

Additional Forms Needed for Personal Counseling Appointments

Form / Document Title	Format	Format
Consent for Counseling	Word
Current Concerns	Word

Documents for Students, Staff, Faculty, and Managers

Form / Document Title	Format	Format
Assisting the Emotionally Distressed Student	Word	PDF
Emergency & Accident Procedures	Word	PDF
Health Center Hours	Word
Preventing Violence	Word	PDF
Student Satisfaction Survey	Word	PDF
Campus Map	Word