myCSUSM
Patient Forms
o 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
| Form | Info |
|---|---|
|
To obtain your medical records from SHCS, obtain your medical records from another medical provider or authorize verbal communication of personal health information, this form must be completed.
|
|
|
To obtain your mental health records from SHCS, obtain your mental health records from another counselor or agency, this form must be completed. |
|
|
If you are a student 17 years of age and under, a parental/guardian consent must be signed in order to be seen at SHCS. |
|
|
For new patients, a health history form must be completed priorto your clinic visit in order to provide you with outstanding health care. |
|
|
Consent for Counseling services. |
|
|
If you are a student 17 years of age and under, a parental/guardian consent must be signed in order to be seen for mental health care at SHCS. |
|
|
Tuberculosis (TB) Risk Assessment Questionnaire
|
|
|
This nutrition assessment form is for new clients who will be seeing the Registered Dietician for the first time. |