Forms

Forms required for treatment.

Health History Form

This form must be completed at your first visit to UMKC Student Health and Wellness. The purpose of this form is to provide information on your medical history, current medications, allergies and family history — all of which is extremely important for both you and your health care providers to know.

Consent-Authorization for Release of Information Form

This form gives UMKC Student Health and Wellness permission to send, receive, or share your personal medical history. We will never share any of your medical records until we have received your permission.

Consent to Treatment of Minors Form

If you are under the age of 18, we are not able to treat you until we have this form completed by a parent or legal guardian.

Consent for Treatment Form

This form states that you are permitting us to provide you care; it MUST be signed by you. Typically, you will sign this form electronically at the kiosk when you arrive for your visit; however, this form may be printed and used if our computer system is down.

Forms for assistance with vaccination for Human Papillomavirus (HPV)

Information on Human Papillomavirus (HPV)

This form is the application to apply for assistance on receiving the GARDASIL-9 vaccine.

Information on GARDASIL-9