New Student Medical Form Gonzaga University printable pdf download

Student Health Center

502 East Boone Avenue

Spokane, WA 99258-2506

509.313.4066 direct

509.313.5516 fax

studenthealth@gonzaga.edu

Welcome from all of us at the Gonzaga University Student Health Center!

This packet contains important information about the healthcare services we provide at Gonzaga University as well as some

forms for you to fill out so that we can best care for you. Please be sure to return your completed forms to the Student Health

Center by August 1.

As you review this information and complete these forms, please let us know if you have any questions.

Sincerely,

Libby Skiles

Director, Student Health Center

New Student Medical Forms

There are a few different medical forms that you will need to fill out and return to the Student Health Center. This information

will assist our healthcare professionals in managing any medical illnesses or injuries you may experience while at Gonzaga.

Forms may be returned via the enclosed prepaid envelope, scanned and emailed to

studenthealth@gonzaga.edu

or faxed to

the Student Health Center at (509) 313-5516. Failure to return these forms by August 1 will impact your ability to

1. Patient Information. I n addition to the information requested on this form, please include a copy (front and back) of

your insurance card.

2. Treatment Authorization for Minors. If you are going to be under the age of 18 when you arrive at Gonzaga, the

Student Health Center requires a parent or guardian to sign the Treatment Authorization section of the Patient

Information form.

3. Health History. We ask that you complete this form as accurately as possible to let us know of any ongoing health

concerns you may have.

4. Meningitis and HPV Acknowledgement. W ashington State law requires that all students be informed about

meningitis and human papillomavirus, including causes, symptoms, and vaccinations.

5. Immunization History. Gonzaga requires verification of measles (Rubeola) immunity for all students. Please provide

your full immunization history with special attention to the measles requirement.

Healthcare Services and Charges

Our healthcare services are available to all Gonzaga University students, regardless of insurance provider. There is a minimal

cost to see our Board Certified Family Medicine Physician or Advanced Registered Nurse Practitioners. Students may pay cash,

credit, or charge this amount to their student account. There may be an occasional need for diagnostic tests that cannot be

performed in the Student Health Center. We strongly encourage students to have medical insurance to cover these costs.

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Updated: 1/14/15

New Student Medical Form Gonzaga University