Forms

We recommend that these forms are typed and completed before your clinic visit. Only complete the forms that correspond to the nature of your visit. We accept original handwritten signatures only (if signatures are needed). Always bring your UTSACard each time you visit the clinic. If you have an insurance card, please bring it with you.

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 (PDF)

Forms to be completed prior to receiving immunizations.
Bacterial Meningitis Screening Information and Consent (PDF)
Hepatitis A Screening Information and Consent (PDF)
Hepatitis B Screening Information and Consent (PDF)
HPV Screening Information and Consent (PDF)
Influenza Screening Information and Consent (PDF)
Tdap Screening Information and Consent (PDF)

Release of Information from Medical Records.
Release of Medical Records From Student Health Services to another Entity (PDF)
Release of Medical Records to Student Health Services from another Entity (PDF)
These forms allows you to release Protected Health Information (PHI) from our clinic to another clinic or yourself or from another clinic to Student Health Services. In order to authorize a release of this information, please read each form carefully and determine if you need to either release medical records from Student Health Services or if you need to release medical records to Student Health Services. Fill out the appropriate form by either typing in the fields or printing it out and writing clearly. Before submitting this document to Student Health Services, please write in your initials, print name and signature on the appropriate lines. Fax the completed form to (210) 458-4151 or mail it to Student Health Services. Give at least three to five 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)