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Student Health Services Center Forms

Meningitis Form

For use by ALL students.

!!Forms For Internal Use Only!!

Herein are forms utilized by health center's staff members.

Medical Record/Physical EXAMINATION 2-page form

For use by students in health majors. The Medical Record page is filled by the STUDENT only. The Physical Examination page is COMPLETELY filled by the HEALTHCARE PROVIDER only.

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.

Permission to Release Immunization Records

This form is used to give permission to the Student Health Services Center to send your immunization records to another institution or facility.

Immunization Record Form

For use by ALL students. This form is completed and signed by the student ONLY. If the student is less than 18 years then the parent/guardian signs the form.