Students Health Center Forms
Forms and Documents
- Affidavit for exemption to medical requirements
- Urgent/emergency care centers and summer care providers
- Freshman Counseling Center Survey form
- Program/presentation request form
This form is required by Student Health Services. All students must have a completed form on file. This form must be completed by a healthcare provider and signed by the student or guardian if the student is under the age of 18.
Information on meningococcal disease
Release of Information forms
- Medical provider to SHS (use if sharing SHS records with parent, dean or provider)
- SHS to another provider (use if sending records from home provider to SHS)
- Student Health Services strictly adheres to all state and federal regulations pertaining to confidentiality of medical records.
- A release of information form must be completed when a student makes any request for their patient information to be released to parent, family practitioner, referral doctors or anyone else.
- This form or a written request (must include DOB/School attended/specific information requested and where to send or Fax information/signed and dated) must be completed by an enrolled student requesting copies of his/her medical file.
- Copying charges may be applied and billed to your student account.
- The completed release form or written request may be mailed, faxed or hand delivered to Student Health Services and the request will be handled as promptly as possible.
- Fax requests for records by another physician must be accompanied by a signed request for release of medical records and will be sent at no charge, fax: (909) 621-8472.
- We do our very best to see that all requests are addressed promptly. However, during the summer break (June – August) it may take up to 15 business days to provide the information requested.
Mailing Address for forms sent to Student Health Services:
- Student Health Services
- Medical Records
- 757 College Way
- Claremont, CA 91711
Or email to: firstname.lastname@example.org