University Of West Florida Mandatory Immunization Health History Form Page 3
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3Mandatory Immunization
Health History Form
Date of Birth:
___________________
Full Legal Name: __________________________________
(MM/DD/YEAR)
UWF Student ID:__________________________________ Contact Phone:__________________________
MEDICAL TREATMENT CONSENT: (Signature of student required below – if student is under 18, parent signature also
required)
I hereby authorize UWF Student Health Services to evaluate and employ diagnostic procedures and to render any treatment or
medical, surgical, psychological or psychiatric care deemed necessary for my health and well-being. I grant permission for the transfer
to an accredited hospital or other health care facility if deemed necessary by the medical or mental health provider. (Signature(s)
Required)
_______________________________
__________
___________________________
________________
__________
Signature of Student
Date
Signature of parent/guardian
Relationship to
Date
(if student is under 18)
student
Required Immunizations
***NOTE: ALL TITERS MUST HAVE LAB REPORT ATTACHED***
Month/Day/Year
Month/Day/Year
Month/Day/Year
Titer Date & Result
st
1. MMR (2 doses after 1
birthday)
DO NOT WRITE HERE
OR Measles
DO NOT WRITE HERE
Mumps
DO NOT WRITE HERE
Rubella
DO NOT WRITE HERE
2. Hepatitis B (or sign waiver below)
3. Meningococcal Meningitis
DO NOT WRITE HERE
DO NOT WRITE HERE
(OR sign waiver below)
An official stamp from a doctor’s office, clinic, or health department AND an authorized signature must appear here
for any immunization records listed above to be valid.
____________________________________
___________________________________
_____________________
Official Office Stamp Here
Physician or Authorized Signature
Date
FOR EXCEPTIONS/WAIVERS: (Signature(s) only required in this section if you are applying for an exception/waiver)
I meet one of the 4 criteria for the
MMR vaccine
exception. (additional documentation is required)
To apply for MMR waiver, Check all that apply: (definitions found )
O Active Duty Military
O Medical Basis
O Online Students
O Religious Basis
I have read the information about the
Hepatitis B exception
and decline receipt of this vaccine.
I have read the information about the
Meningococcal Meningitis exception
and decline receipt of this vaccine.
_______________________________
__________
___________________________
________________
__________
Signature of Student
Date
Signature of parent/guardian
Relationship to
Date
(if student is under 18)
IMPORTANT! KEEP A COPY OF THIS PAGE AND ALL LAB REPORTS FOR YOUR RECORDS
Email, Fax, or Mail only this one (1) page (and lab reports as needed) at least three (3) weeks prior to registration
Email: immunizations@uwf.edu; Fax: (850) 857-6100; Mail: University of West Florida, 11000 University Pkwy,
Building 960 – Suite 106, Pensacola FL, 32514.
(PLEASE ALLOW 48 HOURS FOR PROCESSING ONCE RECEIVED)
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