Patient Forms

TB Health Assessment Form

If your TB Risk Screening shows you to be at higher risk based upon your responses on the High Risk TB Screening Questionnaire (found online on the WH&CS Student Health Portal), then you will need to have further testing completed by your Primary Care Provider or other licensed healthcare provider.

  • Download the TB Health Assessment Form and take it to your Primary Care Provider or other licensed healthcare provider who is unrelated to you.
  • Once any additional TB testing is complete and your physician or other licensed healthcare provider has determined that you are free of active TB, the provider must complete and sign the form.
  • Logon to the secure Wellness, Health & Counseling Services (WH&CS) Student Health Portal and upload the completed and signed TB Health Assessment Form for submission to SHC.

Students who do not show risk factors for TB as indicated by their responses on the High Risk TB Screening Questionnaire are not required to complete/submit a TB Health Assessment Form to the Student Health Center.

Vaccination Medical Exemption Request

This form is used to request a medical exemption if a required vaccine is not advisable due to a medical condition. Download the form and have it completed by a licensed physician unrelated to you. The form can be emailed, faxed, or mailed to Student Health Center, Attn: Medical Records. If you need assistance in completing the exemption form, a nurse at SHC can assist you. Please call (949) 824-5304 to make an appointment. Please note that exemptions from UC's immunization requirements are no longer permitted for personal or religious beliefs.

Authorization for Medical and/or Psychological Treatment of a Minor

This form should be completed by the parent of any student who is not yet 18 years old at the time they enter campus. By having authorization to treat a student on file, students who are still 17 years of age may seek treatment at Student Health without significant delays.

Request for Access to Medical Records

This form is used to request a copy of medical records for the patient.

Authorization for Release of Health Information

This form is used to authorize the release of medical information from Student Health Center to a third party, not the patient. Please note, charges may apply.

Note: This form is for the release of information from Student Health Center only. Release of information from your insurance carrier may require a separate form, which you may obtain from the carrier.

Authorization for Disclosure of HIV Test Results

This form is required for disclosure of HIV test results to a third party, not the patient. Please note: Student Health Center policy, in accordance with CDC guidelines, is that HIV test results will not be disclosed until after the patient has received the results in person at the Student Health Center, unless an in-person results consultation is not possible. This form does not change that policy or permit disclosure to the patient in lieu of an in-person results consultation.

Health History for Women

This form should be completed by the patient prior to a Women's Health Exam. The patient should bring the completed form with them to the exam.

Service Issue

Please use this form to notify us of any service related complaint, compliment, question or concern. You may complete and submit this form anonymously if that is your preference. Completed forms can be mailed or faxed to the SHC at the address or fax # noted below, or dropped in the designated Service Issue box in the lobby of the SHC. DO NOT EMAIL this form as it may contain protected personal and/or health information.

501 Student Health
Irvine, California 92697-5200
Attn: Credentialing, Quality and Compliance Dept.
Tel: 949‑824‑5301
Fax: 949‑824‑1378