Patient Forms

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)

Referred to an outside clinic or hospital?  Please use this specific Authorization for the Disclosure of Health Information (download for fillable form) 

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 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