Central Michigan University

Downloadable Forms

Health Forms

Complete these forms and bring them with you to your first visit at University Health Services.  With your health history and immunization records on file, we will have up-to-date information to aid in your care.

If you don't yet have a scheduled appointment, feel free to complete these forms and mail them to us at:

Medical Records
University Health Services
Foust Hall 200
Mt. Pleasant, MI  48859

Pre-entrance Health History Report

• Pre-entrance Health History Report (HS275A-R11/27/07)(pdf)

Pre-matriculation Immunization Recommendations

• Pre-matriculation Immunization Recommendations (HS399-R1/11/07/-Immun-Rec) (pdf)
  
• Pre-matriculation Immunization Record (HS275B-R12/07/07/) (pdf)
  
• Health Insurance Information/Consent to Treat Minor HS275C-R11/27/07/) (pdf)
  

Pharmacy Forms

Pharmacy Patient Registration Form

• Pharmacy Patient Registration Form (HS364A) (pdf)

Pharmacy Delivery Authorization Form

• Pharmacy Delivery Authorization Form (HS366A) (pdf)
  

Pharmacy Notice of Privacy Practices Acknowledgment

• Pharmacy Notice of Privacy Practices Acknowledgment (HS348B) (pdf)
  

Women's Health Forms

• Sexual Health Services Information Sheet (pdf)
• Confidential Women's Health History Form (pdf)
  

Health Insurance Forms

• See CMU Student Health Insurance Plans