Downloadable Forms

To expedite your visit to the University Health Center, below you will find a number of forms which you may print out, complete and bring with you. All documents are PDFs.

Patient Rights and Responsibilities
No signed form is needed, but you are encouraged to: View Patient Rights and Responsibilities

Patient Registration Forms
Bring to your first University Health Center visit each academic year Power of Attorney for Patients Under 19
Bring to your first University Health Center visit each academic year: Patient Pre-Registration Form

Clinical History Forms
Bring to your first University Health Center visit each academic year: Medical History Form
For yearly examinations: Gynecology History Form
Bring to your first visit for allergy injections: Allergy History Form
TB (Quantiferon) Screening Questionnaire

Permission for Use or Disclosure of Your Health Information
Request for Access to Patient's Own Record
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.
New Authorization for Release of Information

Travel Clinic Forms
Bring the following to your appointment: Travel Medical History Form
Patient Pre-Registration Form
Your previous immunization records
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

University Health Center Services Forms
Dental Office Bring to your first appointment:
Patient Pre-Registration Form
Counseling and Psychological Services Unavailable at this time
Nutrition Services Bring to your first appointment:
Nutrition Questionnaire and Food Log
Flu Shots 2016-17 Flu Shot Form for UNL Students

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