Students Health Center Forms

Entrance Physical
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. Please read prior to completing this form:
Release of Information
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. There is a copying charge of $1.00 for this service. Students who have graduated may request copies of their files for a copying charge of $5.00 (check or money order). The completed release form or written request (must include DOB/School attended/date graduated/specific information requested and where to send or Fax information/signed and dated) may be mailed 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 requested are addressed promptly; however, during the summer break (June – August) it may take up to 15 business days to provide the information requested.
Vaccine Information and Consent
This form is to be completed in advance of attending a scheduled appointment by a student seeking vaccinations for travel abroad or general vaccinations.
SHACS Program/Presentation Request form
For more information or questions on those workshops, contact Elizabeth Wilmott, HEO Coordinator or call 909-607-3602.
Mailing Address for forms sent to Student Health Services:
  • Student Health Services
  • Medical Records
  • 757 College Way
  • Claremont, CA 91711
Or email to: shsrecords@cuc.claremont.edu

Last updated: 9/20/2013 12:34:08 PM