Student Health Services Forms

Patient Registration Form

If you are a new patient at Student Health Services, please visit the Patient Portal and complete the Patient Registration Form before your first appointment. For further information, please call: 507-389-6276.

Releasing Your Medical Records

To get a copy of your medical records released to or from another clinic or individual, please print and complete the Authorization of Disclosure of Health Information Medical Records Release Form and return to Student Health Services in person or by Fax 507-389-5787.

In some instances, special information is requested to ensure we get the proper records to continue your medical care.  The following forms are for records to be sent to Student Health Services from another facility:

Students under the age of 18 required parent/guardian consent to be seen at Student Health Services:

Immunization Record Required for Admission

The State of Minnesota requires student to provide dates for specific vaccinations. This form is required if you graduated high school from outside the state of Minnesota or from a Minnesota high school more than 10 years ago.

Information about Health Care Directives