Forms
Please use black ink to complete any of these forms.
| Name | Description | |
|---|---|---|
If you receive regular allergy injections and wish to have these continued at SIUE Health Service, this form will need to be completed by your physician. | ||
This form can be used by your physician to submit your immunization records. Please note that this form is not required and we will accept records in various formats as long as they include your name, date of birth and the provider/school/organization name that is supplying the record. | ||
This can only be submitted within 10 days of receiving a late immunization fine. You must be compliant with all immunization requirements to be considered for a fine waiver. THE DEADLINE FOR SUBMITTING THIS FORM FOR THE SPRING 2025 TERM HAS PASSED. | ||
This form should be completed by your physician if you have a medical condition that precludes you from receiving a specific immunization. | ||
This form is to be completed by a student (if age 18 or older) if they want to request exemption from immunization requirements due to their religious belief. | ||
This form is to be completed by the parent/guardian of a student who is under the age of 18 and seeking treatment by SIUE Health Service. | ||
This form is to be completed by all new international students upon their arrival to SIUE. It will determine if a TB screening lab test will need to be performed at SIUE Health Service. | ||
This form will be completed by a student wanting to have their medical records sent to SIUE Health Service by another provider. It is also used to request SIUE Health Service to send their medical records to another provider. | ||
Patient Information for Therapeutic/Allergy Injections | ||
If you receive regular therapeutic injections and wish to have these continued at SIUE Health Service, this form will need to be completed by your physician. | ||
If you are concerned about a student that you believe may be at risk of harm, or who may intend to harm others, please feel free to use this form to communicate your concern to someone at the university. | ||
Optional Disclosure of Mental Health Information | ||
New Client Information | ||
This link will enable students to access OQ Analyst so they can sign in to complete the TA assessment after they complete a session with their therapist. | ||
Please see our Training Opportunities for information about the practicum program. To complete an application for the practicum program, please submit two completed Recommendation Forms. |
