Clinic Forms
The Student Health Clinic utilizes a variety of forms to assist students with their appointment or to receive medical records for your visits. If you have questions regarding forms, please call 319-273-2009 opt. 2.
Health Insurance Information Form
You may provide health insurance information to the Student Health Clinic prior to an appointment or if your insurance has changed. Please complete the Insurance Information form and return along with a copy of your insurance card (front and back). Students: if you are 18 or older, make sure you sign the form.
Informed Consent for Behavioral Health Services
Students may view the informed consent used for behavioral health services at the health clinic. Please fill out the PDF consent form below.
Treatment of Minors
For students under 18 years of age, a parental or legal guardian authorization for medical treatment form must be on file in our office in order for you to receive prompt care and treatment should the need arise. Please complete and return the Consent for Treatment of a Minor (PDF) form.
Mandatory Health Requirements
Immunization to measles, mumps, and rubella (MMR) is a requirement for all students who attend UNI. To comply with this requirement, all students must provide records documenting proof of TWO measles, mumps and rubella (MMR) vaccinations. Immunization dates must include month, day and year. We also must collect information on the status of student's vaccinations against meningococcal disease. Students can provide both the MMR and Meningitis vaccine on the Health Requirements form. A photocopy of your immunization record should be attached to the Health Requirement Immunization Verification form.
Request Medical Records
To request a copy of your health record, please complete and return the Authorization to Release Protected Health Informaton (PDF) form. All information must be completed in order for your request to be processed.
*Please allow 48-72 hours from receipt of the signed release form for your health information records to be processed. All clinic forms can be faxed to the Student Health Center at: 319-273-7030.