Forms

Student Health Services Forms

The Immunization Record must be completed and signed by a physician, nurse practitioner, or physician assistant. All information must be legible and vaccine dates must contain month/day/year. Immunization record forms must be input and uploaded at the UNCP Patient Portal.

The required Report of Medical History form is for the student to self report (or parent to report if the student is under age 18) information regarding medical conditions, allergies, medications, health history and emergency contact. Students must complete the Report of Medical History electronically by logging on to UNCP Patient Portal. 

This Parental Consent form is required and must be on file for any student under 18 years of age. A parent or guardian must sign and please be sure to include the student’s name and UNCP Banner ID number on the form. Please fax the form to 910.521.6549, or email to shs@uncp.edu.

This Release of Medical information form should be used if a patient is requesting records be sent to another medical office or other third party entity (insurance, law firm, job site, etc). Please fill in information completely and legibly. Allow 2-3 business days for records to be sent. There is no charge for records sent directly to another facility from Student Health Service. Please fax the form to 910.521.6549, or email to shs@uncp.edu.

Student Health Services (SHS) is pleased to administer allergy injections to our students who are under an immunotherapy regimen prescribed by their private physician. Appointments can be made by calling 910.521.6219 or by walk-in availability. All students must complete the ALLERGY INJECTION PARTICIPATION AGREEMENT PACKET. Please fax the form to 910.521.6549, or email to shs@uncp.edu.

Have Questions?

Please feel free to call Student Health Services at 910.521.6219.
Email Us
Student Health Services UNCP