Forms

For Athletes, New Patients and More

Below are links to some of the forms students might need. We have made these forms available online so you can receive quality health care in a timely manner. If you don't find what you need here, or if you have any questions, please contact Student Health Service at 715-836-5360.

Mailing address:

UW-Eau Claire Student Health Service

Crest Wellness Center

PO Box 4004

Eau Claire, WI 54702-4004


Fax: (715) 836-5979

For New Patients

You can either download the New Patient form below, print it out, fill it in and return it at orientation or at your first medical appointment, or you can fill in the form online.

To fill in the form online, go to mySHS and log in with your university credentials (username + password). While you are logged in to mySHS, add your cell phone number if you'd like to get text-message reminders for your upcoming appointments. Also, please check your profile to be sure your contact information is correct.

Form

For Athletes

Forms

For Students With Chronic Medical Conditions

Form

To Transfer Contraception Prescription

Form

To Release Medical Information

If you are 18 or older, your medical information is confidential. As your health care provider, we are legally required to protect the privacy of your health information.

To release your medical information from Student Health Service to your parents, to another doctor or facility, or to someone else, please select the Prefilled form for Release of Medical Information, download and print out.

To release medical information from a facility or doctor other than SHS, print out the Blank form for Release of Medical Information.

Forms
Tips for completing Release of Medical Information form
  • Fill out the patient information completely.
  • Include name and contact info for the person(s) or entity receiving the information.
  • Check the boxes for all information you want to be released. Use the "other" line if needed, being as specific as possible.
  • Within the boxed area, mark any records that need special permission to be released (e.g. Mental Health records).
  • Select the purpose of releasing this information.
  • Sign and date the document
  • You must include your written signature - a name typed onto the signature line is not acceptable.
  • For the blank form, you must also fill in who will be releasing the information.
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