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Forms

To expedite your appointment, please complete the New Patient Intake Form.

The Earle Student Center staff require several forms to be completed in order for students to remain compliant while at Furman University. New students must create a MyChart account by June 15.  Once created, new students must also complete the appropriate Health and Immunization Questionnaire by June 15.  If you are unable to acquire original documentation regarding your immunization record, contact your primary care physician. Furman is strongly encouraging students get the COVID-19 vaccine for the fall semester.

Students who have a particular medical or religious exemption will need to complete the Immunization Waiver Form [PDF] in order to be compliant with the university’s immunization requirements. If you already have an official form provided by your home state, religious organization, or healthcare provider, we can accept these forms. Please ensure that the form has a professional signature from either a religious affiliate or healthcare professional.

Students may give authorization for disclosure of medical information to a family member or other individual by completing the HIPAA Waiver [PDF].

Many current and former students may need immunization records. These individuals must complete the Authorization to Disclose Protected Health Information [PDF]. When completed, please email this form to furmanstudenthealth@prismahealth.org.