Forms

Immunization Fax:      (252) 328-4007

Medical Records Fax:  (252) 328-0462

Immunization Record

The Immunization Record must be completed and signed by a physician, nurse practitioner, or physician assistant. All information must be legible and vaccine dates must contain month/day/year. Immunization record forms must be returned by fax, mail, or dropped off in person to Student Health Service.

Report of Medical History

The required Report of Medical History form is for the student to self-report (or parent to report if the student is under age 18) information regarding medical conditions, allergies, medications, and insurance coverage. Students must complete the Report of Medical History electronically by logging on to myPIRATEchart and selecting “Medical History” from the left-hand menu.

Parental Consent for Treatment of Students Under 18

The Parental Consent for Treatment of Students Under 18 is required and must be on file for any student under 18 years of age to receive treatment at Student Health Services. A parent or guardian must sign the consent.

Medical Record Release Forms

Parental/Legal Guardian Request for Access to a Student’s Medical Records
Students over 18 years of age who wish for Student Health Services to discuss their medical record with a parent/legal guardian may request a release form from SHS staff. This form must be signed in person by the student and expires at the end of the academic semester in which it is signed. We do not accept forms prior to the first day of class for new incoming students.

Individual’s Request for Access to Health Information

Students should use the Individual Request for Access to Health Information to have records sent directly to themselves. Allow 2-3 business days for records to be sent. 

Authorization for Use and Disclosure of Health Information to a Third Party (another office, insurance, etc)

The Authorization for Use and Disclosure should be used if a student is requesting records be sent to another office.  Allow 2-3 business days for records to be sent. There is no charge for records sent directly to another facility.

Lab Forms

Outside Lab Order Form

Students who have lab orders from another provider can have their lab work performed conveniently at SHS. The Outside Lab Order Form should be filled out by the ordering provider; ALL fields are required for SHS before an appointment can be made at SHS to perform the labwork. Once SHS verifies that all information has been received, the student will be contacted by SHS staff to schedule their lab appointment.