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Patient Forms

To be seen at Student Health & Counseling Services, there are several forms that you are required to complete prior to your appointment. The medical receptionist may ask you to download the following patient forms below to fill out and bring in to your next clinic appointment.

Please remember that all documents require your signature in order for it to be a valid document.

Downloadable Patient Forms

 Consent to Release Medical Records
To obtain your medical records from another medical office or to obtainyour medical records from SHCS, this form must be completed.

To obtain your Psychiatric Records-
Consent for Psychiatric Records
Minor Parental Consent
If you are a student 17 years of age and under, a parental consentmust be signed in order to be seen at SHCS.
 Health History and Treatment
For new patients, a health history form must be completed priorto your clinic visit in order to provide you with outstanding health care.
 Certificate of Immunization
To clear your MMR and Hepatitis B immunization, this form mustbe completed and signed by your medical provider identifying thetype of vaccine given and the date it was given. If you have your vaccination card, you may bring it in to SHCS for clearance.
 Initial GYN History Form
For patients who have never had a pap exam with us, this form mustbe filled out prior to the gynecological exam. 
 Interval-Annual Pap Form  
For patients who are coming in for their yearly gynecological exam,this is a short updated pap form that must be filled out prior to the appointment
 Oral Contraceptive Screening Form
For patients who are coming  in for a refill prescription on their oral contraceptives, this is a short updated form that must be filled out prior to the appointment.
  Your GYN Exam  Informational handout regarding the pap exam.


Consent form for patients who are interested in starting ahormonal birth control and requesting a prescription at SHCS.
 Confidential Client
Contact Information
Contact information form for counseling patients.  
 Confidential Client Information 
Information form for counseling patients.
   Consent for Counseling  
Consent for Counseling services.