Patient Forms

Incoming Student Health Form 2017-18

This form is used to report on immunization history and tuberculosis exposure when students are not in possession of their immunization records. Student Health Center will accept immunization history on this form, from a copy of the "yellow card" immunization history, or from a copy of a high school transcript showing the student's name and immunization records. Only one form or proof should be submitted. This form is not required if a copy of the yellow card or high school transcript showing immunizations is submitted.

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