Patient Forms

Forms required for new patients

New patients are encouraged to complete the following form prior to their first appointment. In an effort to save you time, print off and complete this form prior to your first appointment. Present these to the registration clerk at the time of check in. All forms, if not completed online, must be completed in ink. All forms will be kept confidential, unless permission is granted to share information with relevant parties. 

Assignment of Benefits

Forms to be completed as needed (forms are fillable, unless indicated)

Immunization Record Form 

Authorization for the Disclosure of Health Information 

Patient Communication Form 

Treatment of a Minor, Consent and Authorization form  (not fillable)

Immunization Documentation

All students, except for those who graduated from a Minnesota high school in the year 1997 or later, must have immunization documentation on file at Health Services. All graduate students and transfer students must also have their records on file. Students must turn in their Immunization Record Form to health services in order to register for classes. A one-semester grace period will be allowed in cases of non-compliance. If the immunization record is not submitted prior to second semester, a hold will be placed on a student's record, and he/she will be unable to register for classes.

Minnesota residentsMinnesota Immunization Information Connection (MIIC) is a statewide system that collects electronic immunization information. Patients can request their immunization record from MIIC.  Not all clinics enter data so your record may be incomplete.

Wisconsin residents: Access your public WI immunization records. You will need to input some personal information (First and Last Name, Date of Birth, Social Security Number) and then you can print your records.

Forms for patients to review for privacy of health information