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University Health Center

Downloadable Forms

Below you will find a number of forms which you may print out, fill in, 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.

Clinics

• Medical History Form (Bring to your first UHC visit)
• Women's Health History Form (For yearly examinations)
• Allergy History Form (Bring to your first visit for allergy injections)
• Camper Registration and Authorization Form (if you are attending a summer camp at UNL)

Patient Assistance

• Gardasil Patient Assistance Information
• Gardasil Patient Assistance Application

Pre-Enrollment Health Requirement Form

• Pre-Enrollment Health Requirment Form

Registration and Insurance

- Bring to your first UHC visit of each academic year

• UNL Healthy Option Student Insurance Information Form
• Insurance Information Form (For all other insurances, i.e. Blue Cross/Blue Shield, Coventry, Midland's Choice, Tricare, etc.)

Medical Records

- Permission for use or disclosure of your health information

• Authorization for Use or Disclosure of Health Information - Medical
• Authorization for Use or Disclosure of Health Information - Dental

Studying Abroad

• History and Health Clearance Form

Counseling and Psychological Services

• Confidential Personal Data Sheet
• Presenting Problems

Flu Shot

• Influenza Vaccine Information Statement (VIS)
  
• UNL Student Seasonal Influenza Vaccination Consent Form
  
• Seasonal Influenza Vaccionation Consent Form
  
• Under 18 Seasonal Influenza Vaccination Consent Form
  
• Medicare Seasonal Influenza Vaccination Consent Form