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. Image removed.

Allergy Clinic

Class Excuse Self-Signed Note

  • The template can be found here.

 Immunizations

Medical Records

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
Initial Asbestos
Periodic Asbestos
Respirator Physical
Employment Physical

Vaccinia (Small Pox)

Student Involvement Immunization Form

Physical Therapy