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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

Form Info

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/guardian consent must 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.

 
Birth Control Consent Form

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.

Minor Consent for Mental Health Care

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.