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Forms

Required forms for new students – due June 15, 2022:

Other Forms

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

Students who have a particular medical contraindication or religious exemption to immunizations and vaccinations will need to complete the Immunization Exemption Request Form [PDF] in order to be compliant with the university’s immunization requirements. Please ensure that the form has the appropriate required signatures.

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.