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York College Student Health Services Center

Forms

Immunization Record Form
The Immunization Record form is completed and signed by the student ONLY. If the student is less than 18 years then the parent/guardian signs the form.

Medical Record/Physical
ONLY the student fills the Medical Record page. ONLY the healthcare provider fills the Physical page.

Meningitis Form
For graduates of NYC High Schools with MMR vaccines in CUNYFirst or transfers from another CUNY college or continuing students whose meningitis expired.

Meningococcal Information
New Recommendations for Meningitis.

NYS Refer To Quit
The New York State Smokers’ Quitline offers its Refer-to-Quit program for health care providers to help their patients stop smoking. As a confidential service, we offer coaching and cessation-related services to patients who use tobacco products.

!!Forms For Internal Use Only!!
Herein are forms utilized by health center's staff members.

Email StudHealthSvcCtr@york.cuny.edu if you need assistance. Follow us on twitter @york_health for updated information.