Required Health Information Form printable pdf download

For office use only:

Registration Date:______________

 Fall Semester 20_____

 Spring Semester 20____

HEALTH CENTER

1450 Alta Vista St. | Dubuque, IA 52001 | Phone: (563) 588-7142 | Fax: (563) 588-7659

Required Health Information

Please Print. Complete front and back in English and return to the Health Center.

LORAS I.D. # (if available) _______________ BIRTH DATE: ___/___/_____ CELL PH. #: (______)________________________

mo. / day / year

NAME: ____________________________________________________________________________________________________

Last

First

Middle

HOME ADDRESS: ___________________________________________________________________________________________

Street

City

State/Country

Zip

GENDER:_______________

INTERNATIONAL STUDENT: Yes___

No___

Do you plan to participate in any Loras College intercollegiate sports? Yes___ No___ Sport(s)_______________________________

FATHER’S NAME: ___________________________________________________________________________________________

Last

First

FATHER’S PHONE: Home ________________________ Work ________________________ Cell ________________________

MOTHER’S NAME: __________________________________________________________________________________________

Last

First

MOTHER’S PHONE: Home ________________________ Work ________________________ Cell ________________________

PERSON TO NOTIFY IN EMERGENCY OTHER THAN PARENT(S): __________________________________________________

________________________

(______)__________________

Relationship

Home Phone

Work Phone

Cell Phone

HEALTH INSURANCE COMPANY: __________________________________________________________________________

POLICY NUMBER: ____________________________________________________/Gr.#__________________________________

POLICY NAME: ________________________________________ BIRTH DATE OF HOLDER: M_____ D _____ Y _______

CUSTOMER SERVICE PHONE NUMBER: _____________________________________________

STUDENT SHOULD CARRY A COPY OF THE INSURANCE CARD—VERY IMPORTANT INFORMATION in an emergency!

Please attach front and back copy of Insurance Card

Provide a list of Physicians in Dubuque that your insurance has approved for medical services:

____________________________________________________________________________________________________________

Privacy of confidential information is a social, legal, and ethical responsibility of organizations that receive medical

information. The Loras College Health Center has a policy to protect the confidentiality of patient data, whether it is

electronic or printed information.

All patient records maintained by the Health Center are private. Only authorized Health Center personnel may release

patient records, and then, only with written authorization from the patient. Parents of patients eighteen years and older,

parents or spouses of emancipated minors, and other next of kin will not have access to the medical record without the

written consent of the patient.

Rev.: 11/06; 3/08; 12/08; 3/13, 1/2014

Required Health Information Form

Related Articles

Related forms

Related Categories