Downloadable Forms

Below you will find a number of forms which you may print out, fill in (forms marked with * can be filled out online), and bring into the UHC to expediate your next visit. All documents are in the .pdf format and require a .pdf reader such as Adobe Acrobat to view. For a free download of Adobe Acrobat visit the Adobe Website.

Clinical History Forms

• * Medical History Form (Bring to your first UHC visit)
• * Gynecology History Form (For yearly examinations)
• * Allergy History Form (Bring to your first visit for allergy injections)
• Study Abroad History Form (Students)
• Travel Medical History Form
• TB (Quantiferon) Screening Questionnaire

Gardasil Patient Assistance

• Gardasil Patient Assistance Information
• * Gardasil Patient Assistance Application

Pre-Enrollment Health Requirement Form

• * Pre-Enrollment Health Requirment Form

Authorizations and Insurance

- Bring to your first UHC visit of each academic year

• Insurance Information Form

- Permission for use or disclosure of your health information

• * Authorization for Release of Information-Medical
• * Authorization for Release of Information-Dental
• * Camper Registration and Authorization Form (if you are attending a summer camp at UNL)

Dental Office

• Dental Registration Form

Counseling and Psychological Services

• * Confidential Personal Data Form
• Minor Consent (for students 18 and younger)

Nutrition Services

• Nutrition Questionnaire
• Food Log

Flu Shot

• Flu Consent Form
• Influenza Vaccine Information Statement (VIS)