Forms
To minimize your wait time at the Health Center, we have provided you with some forms to print and fill out prior to your appointment.
All files are in PDF format. You'll need Adobe Reader to view these files. 
Class Excuse Documentation Policy
- Click here to read the policy.
Allergy Clinic
- Allergy Clinic Questionaire
- Allergy Injection Policy
- Allergy Injection Informed Consent
- Allergy Clinic Guidelines
Business Office
- Patient Authorization to Release Protected Health Information (PHI) (for faster processing, please fax form to (301) 314-9816)
Immunizations
- Hepatitis B Vaccine Information
- HPV vaccine consent form
- Immunization Record (Required)
- Influenza Vaccine
- Flu Mist
- TB Skin Test Screening Questionnaire
- General Vaccine Consent Form
Medical Records
- Class Excuse Policy
- HIPAA (See also Notice of Privacy Act)
- Patient Authorization to Release Protected Health Information (PHI)
Mental Health
- Prior to your first appointment at the Mental Health Service, go to myuhc.umd.edu and complete the questionnaires for your appointment (you must have an appointment scheduled in order to be able to complete the paperwork). Don't forget to click "SUBMIT" when you are finished. Please do not print the questionnaire and bring it to your appointment. If you are unable to complete this paperwork prior to your appointment, you can arrive 20 minutes early to your appointment to complete the questionnaire on one of our computers.
- Alcohol and Substance Abuse Screening Form
- Please read Notice of Privacy Practices
- Patient Authorization to Release Protected Health Information (PHI)
Occupational Health
- Animal Handler Questionnaire
- Notice of Privacy Practices (Please review before completing the form below. Printing is not required.)
- Animal Handler Questionnaire (Please read and sign)
- Initial Asbestos
- Periodic Asbestos
- Respirator Physical
- Employment Physical
