Â鶹ÊÓƵ

Medical work often requires forms. Below you’ll find descriptions of the most commonly needed or required forms for the Student Health Center. Many of our forms are now available for you to complete online at the Student Health PortalÌýbefore your appointment. These online forms include the Women's Health History Form and Initial Psychiatric Assessment form. These forms must be completed online before your scheduled appointment.

Mandatory Immunization Form
Â鶹ÊÓƵ and the District of Columbia require that all students under the age of 26 show proof of the following immunizations:

1. One Tetanus and Diphtheria booster given within the past 10Ìýyears
2. Two vaccinations against Measles, Mumps, and Rubella (MMR) given after age one and at least 30 days apart
3. Two vaccinations against Varicella (Chickenpox) given at least 30 days apart, or a history of Chickenpox verified by titer resultsÌýÌýÌýÌýÌýÌýÌýÌýÌýÌýÌý
4. Completed Hepatitis B Vaccination- Either Three vaccinations against Hepatitis B, dose 2 given 30Ìýdays after dose 1, dose 3 given four months after dose 2 orÌýHeplisav Two Dose Series
5. One Meningococcal (Meningitis) vaccineÌýACWY given after a students 16th birthday - required for first year students andÌýfor students living in residence halls

Please complete the Immunization History form on the Student Health Portal and upload a copy of your immunization form for review. You will receive a secure message when your information is reviewed.

Meningitis Waiver
First year students and student living in university-sponsored housing who do not wish to receive the meningitis vaccination can sign the meningitis waiver form stating they are aware of the risks of the disease and do not wish to be vaccinated.

Release of Medical Records Form
If you need a copy of your medical record, a Release of Medical Records form must be filed. This allows the Student Health CenterÌýto provide you or the health care facility of your choice the specified portion of your medical record. There is a fee for this service. The first 10 pages are $1 per page, anything over 15 pages is $15.

Permission For Medical Treatment
This form authorizes Â鶹ÊÓƵ'sÌýStudent Health Center to administer care and treatment. Such care may include evaluation and treatment of injuries and illnesses, the administration of medication orally or by injection, and/or psychiatric evaluation and consultation.

Psychiatric Assessment Form (Only Available Online)
This form includes important information for the Psychiatric Nurse Practitioner about your health history.

Psychatric Informed Consent
This form includes important information about your care, treatment, services, and responsibilities to receive psychiatric care atÌýthe Student Health Center.

Psychiatric Release of Information
Complete this form if you need to request information from an off-campus mental health provider, or release information from psychiatric appointments in the student health center to someone else.

Psychiatry Telehealth Consent Form
The purpose of this form is to obtain your consent to participate in telehealth services with Â鶹ÊÓƵ's Student Health Center.

ASAC Release of Information
Complete this form to release your psychiatric information from the Student Health Center to the Academic Support and Access Center (ASAC).

ADHD Medication Agreement
All students receiving stimulants in the Student Health Center are required to review and sign this agreement each academic year.

Documentation of Previous ADHD Treatment
Providers, please fill out this form so that this student may continue treatment at Â鶹ÊÓƵ SHC. Please include a copy of chart notes and any information regarding recent prescriptions.

Note:ÌýThose seeking ADHD refillsÌýmustÌýsend psychological/neuropsychological testingÌýpriorÌýto the first visit. WeÌýdo notÌýdo initial ADHD testing or diagnosis.

Annual Exam Sexual Health Questionnaire (only available online)
This form is filled out prior to a routine gynecological examination.