Forms

Here are forms used at Student Health Services. We recommend that these forms are typed and completed before your clinic visit. We accept original handwritten signatures only (if signatures are needed). This will help expedite you through the clinic smoothly. Always bring you UTSACard each time you visit the clinic.

Form to be completed if you are visiting the clinic for the first time.
Student Health History Form (PDF)
*Patients who are 17 years old or younger must have this form completed and signed by a parent/guardian prior to the start of classes.

Form to be completed prior to a Tuberculosis screening.
Tuberculosis Questionnaire (Word Doc)

Forms to be completed prior to receiving immunizations.
Bacterial Meningitis Questionnaire (PDF)

Release of Information from Medical Records.
Release of Medical Records Form (PDF)
This form allows you to release Private Health Information (PHI) from our clinic to another clinic or yourself. In order to authorize a release of this information, please complete this form and submit to Student Health Services via fax or mail. Give at least three business days to process your request and a representative will contact you and discuss the fees involved.
Cost: call for additional information.

Complete this form prior to a Well Women's Clinic appointment.
Women's Clinic Health History Intake Form (PDF)