Patient Forms and Immunization FAQ's

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

Please return any of these forms to the clinic, fax to 888-714-0584 or email them to [email protected].

Immunization Record Form (download for fillable form)

Authorization for the Disclosure of Health Information (download for fillable form, but please note written signature is required)

Referred to an outside clinic or hospital?

Please use this specific Authorization for the Disclosure of Health Information (download for fillable form, but please note written signature is required)

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

Patient Communication Form (not fillable) Please follow instructions on form for submission.

Patients Bill of Rights

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 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. Graduate students and those transferring here from another college, must also submit their immunization record to Health Services, regardless of when they graduated from high school. Students must turn in their student immunization form to health services in order to register for classes. A one time grace period of approximately 8 weeks before a hold will be placed on a student's record. The student will be unable to register for classes. See contact us for these options. If you are having trouble finding your immunization record, we have provided some information to assist you below.

Minnesota residents:

Minnesota 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.

All other states:

Click here to access your immunization records, sorted by state. 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.