Patient Forms

Certain forms listed below may be required for your appointment. Only fill out forms as directed by Nebraska Medicine–University Health Center staff. For questions, call 402.472.5000.

New Medical Appointments
Required form for students who are 18:
For more information on the Power of Attorney form (y en Español):
Power of Attorney for patients who are 18 (Versión En Español)
Power of Attorney form FAQ
Bring to your first University Health Center visit each academic year: Medical History Form

Flu Shots
Bring with you if you attend a walk-in flu shot clinic: 2018-19 Flu Vaccination Form

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: Dental Health History Form

Permission for Use or Disclosure of Your Health Information
Medical and Counseling and Psychological Services – Authorization for Release of Information
Dental - Authorization for Release of 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.)

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.