Immunization And Medical Record Request Form printable pdf download

Immunization And Medical Record Request Form

Immunization and Medical Record Request Form

There is a

5.00 charge for shot/medical records released in-hand or mailed.

We accept Lion’s Lagniappe (I.D.) or a receipt from the Controller’s Office.

NO cash, credit or checks. Thanks!!

Name:

Phone:

W#:

Date of Birth:

What was your 1

semester at Southeastern

(ex. Spring ‘06)

(Retention of medical records is six (6) years. Your records may

have been shredded depending on when your first semester was.)

Have you ever been a patient at this Health Center? Yes

(THIS IS IMPORTANT. DO NOT SKIP)

I am requesting a copy of the following medical information:

[ ] Immunization Record

[ ] Lab Reports

[ ] Consultation Notes

[ ] Women’s Health Info

[ ] Men’s Health

[ ] Allergy Reports

[ ] Medication Records/Summary Sheet

[ ] Physical Exam

[ ] Other: ___________

_______________________________________________________________________________________

I would like my records faxed / mailed / in hand

to:

(circle one)

(School, Business or Person’s name)

The fax number is:

The address is:

(street and number)

(city, state, and zip)

Signature:

Date: ____________

University Health Center

Phone 985-549-2241

SLU 10734

FAX: 985-549-2093

Hammond, LA 70402

Email: health@selu.edu

Immunization And Medical Record Request Form