Patient Forms

To expedite your visit to the University Health Center, you may print out, complete and bring the following forms to your appointment.

New Medical Appointments
Required form for students 18 or younger:
For more information on the Power of Attorney form:
Power of Attorney for Patients Under 19
Power of Attorney form FAQ
Bring to your first University Health Center visit each academic year: Medical History Form - English
Bring to your first University Health Center visit each academic year: Medical History Form - Chinese

New Allergy Clinic Appointments
Bring to your first visit for allergy injections: Allergy History Form

Study Abroad Appointments
For Study Abroad Program Physicals, bring the printed requirements list that you can find on My World, including:
Education Abroad Confidential Health History Form
Education Abroad Health Clearance Form
Travel Medical History Form


Travel Clinic Appointments
Bring the following to every appointment: Travel Medical History Form

New Dental Appointments
Bring to your first appointment: Patient Pre-Registration Form

New Nutrition Services Appointments
Bring to your first appointment: Nutrition Questionnaire and Food Log

Flu Shots
Bring with you when you get your shot: 2016-17 Flu Shot Form for UNL Students

Permission for Use or Disclosure of Your Health Information
Request for Electronic Access to Patient's Own Record (Records of visits after June 28, 2016 may be accessible via your One Chart | Patient portal.)
Medical - Authorization for Release of Information
Dental - Authorization for Release of Information
Counseling and Psychological Services - Authorization for Release of Information
If you visited the Health Center on or after June 28, 2016 (when the Health Center changed record systems):
  • If it was your first visit to the Health Center, complete the following form.
  • If it wasn't your first visit to the Health Center, complete the following form AND the above applicable form.
  • Dental patients DO NOT need to fill out the New Authorization for Release of Information form below, whether you are a new or existing patient. Only fill out the form above.
New Authorization for Release of Information

Miscellaneous Forms
Pre-Enrollment Health Requirement Can be completed online in MyRED - Click here for directions
Student Absence Form

If you are ill and miss classes, please contact your instructors immediately. Your instructors may have you fill out a Student Absence form and return it to them.

If you are attending a summer camp at UNL: Camper/Patient Pre-Registration Form