Student Health Center

Student Health Center Downloadable Forms

 

 

Form Who When
Health History and Immunization Forms
(Detailed Immunization Info can be found here)
Combined Health History & Immunization Record Form (including Meningococcal Acknowledgement and Tubercular Info) ALL* new students must complete this form

Students entering Winter 2011: Due by January 12, 2012 +

Immunization Record Form ONLY ALL* new students must complete this form

Students entering Winter 2011: Due by January 12, 2012 +

Meningococcal Acknowledgement ONLY ALL* new students must complete this form

Students entering Winter 2011: Due by January 12, 2012 +

Request for Religious Exception to Immunization

 

 

Release Form
Authorization for Release of Protected Health Information (PHI)

 

 

*Exceptions: Students taking less than 4 credit hours
+ Failure to comply may result in $200 late fine and possible deregistration from classes.

 


One Lomb Memorial Drive, Rochester, NY 14623-5603
Questions or comments? Send us feedback. Telephone: 585-475-2411