Personal And Family Medical History printable pdf download

University of Delaware – Student Health Service

282 The Green, Laurel Hall, Newark, Delaware 19716-8101

Phone: (302) 831-2226

Fax: (302) 831-6407

Dear ELI Student,

The staff of the Student Health Service is pleased that you have chosen to attend the University of Delaware

English Language Institute. The ELI requires all students to complete this Personal and Family Medical History form;

this form assists the Student Health Service medical staff to provide quality medical care.

ALL MEDICAL RECORDS ARE CONFIDENTIAL

If you are presently under the care of a physician for chronic disease or other medical condition(s), ask your

physician to forward information pertaining both to your medical problem and its treatment to Student Health Service.

This will assist in continuity of your care.

Sincerely,

Timothy Dowling, D.O

Physician/Director

*If you will be under age 18 at the time of your enrollment it is very important that the Student Health Service

have permission from either your parent(s) or guardian(s) to provide medical care until your 18

birthday. Please

have one or both of them sign the consent form below:

I hereby grant permission to the Student Health Service of the University of Delaware to render medical care to my

dependent ____________________________________________.

Name/Relationship _________________________________________/__________________________________

Signed ______________________________________ Date _________________________________

Name/Relationship _________________________________________/__________________________________

Signed ______________________________________ Date _________________________________

EMERGENCY CONTACT INFORMATION

Student Name: _____________________________________________________________________________

Family Name

First Name

Middle Name

Date of Birth: ____________________ Place of Birth ______________________________________________

Name of Parent, Guardian or Spouse: _____________________________________/______________________

Relationship

Address of Parent, Guardian or Spouse _________________________________________________________

______________________________________________________________________

__________________________________

Home Telephone Number of Parent, Guardian or Spouse:

Please include the country code

Names, Addresses and Phone Numbers of Two people to be contacted in case of an Emergency, and in the event that

Parent, Guardian or Spouse cannot be notified:

______________________

Name: _______________________________________ Telephone:

___________________________________________________________

Address:

______________________

Name: _______________________________________ Telephone:

___________________________________________________________

Address:

Personal And Family Medical History

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