Directions For The Medical Form - Auburn University Medical Clinic (Page 3 of 3) in pdf

MEDICAL INFORMATION FORM

AUBURN UNIVERSITY

(CONFIDENTIAL)

MEDICAL LEGAL DOCUMENT – Property of Auburn University Medical Clinic. Information may not be released to a third party unless a

proper acceptable authorization is furnished to the Medical Clinic.

This release must comply with State and Federal Regulations.

Incomplete or inaccurate information may delay your clearance, cancel your registration, or cause improper decisions of your future medical

care.

BEFORE YOU MAIL THIS FORM, be sure to COMPLETE BOTH PAGES…Sign…Have one of your Parents/Guardians Sign

MAIL, FAX or E-Mail TO:

Auburn University Medical Clinic

Phone: (334) 844-4416

ATTN: Medical Records

Fax:

(334) 528-6780

400 Lem Morrison Drive

E-Mail:

Auburn University, AL 36849-5349

GENERAL INFORMATION

Name: _______________________________________________________________________

Social Security # ____________ - ___________ - ____________________

Last

First

Middle

AU User ID/GID ______________________________________________

Home Address: ________________________________________________________________

Student’s Cell Phone: (___________) - ____________________________

City: _________________________________________________________________________

State: __________________

Zip: ____________________

Date of Birth: __________/__________/_______________

Sex (circle one)

Auburn Email Address:________________________________________

Emergency Contact – Name: ____________________________________________________

Relationship: ________________________________________________

Telephone #s HOME: (_______) - _______ - __________

WORK: (_______) - _______ - __________

CELLULAR: (_______) - ______ - __________

Address: ______________________________________________________________________________________________________________________________________

Street / P.O. Box

City

State

Zip

Authorization for medical clinic to treat a minor student (under 19 years of age): ___________________________________________________________________________

(Signature of parent or legal guardian)

List Allergies to medication or other items __________________________________________________________________________________________________________

Student Starting School:

______________________________/______________________________

Semester

Year

MEDICAL DOCUMENTATION

REQUIRED:

TUBERCULIN SKIN TEST (PPD): This is required within six (6) months prior to the first day of class of the semester you enter school. Having a chest x-ray is

NOT an acceptable alternative unless otherwise stated in Appendix A. Anyone with a new or previous positive PPD test, please refer to Appendix A on this form

concerning Tuberculosis protocol.

Date PPD given:

Date results read (must be no earlier than 48 hours and no later than 72 hours):

Results of PPD (MUST BE DOCUMENTED IN MM – NO EXCEPTIONS!)

PLEASE, DO NOT WRITE “Negative”

Documentation / Evaluation _________________________________________________

M.D. Printed Name

__________________________________________________

CLINIC STAMP

M.D. Signature

__________________________________________________

REQUIRED:

A copy of an immunization record with your MMRs documented will be acceptable.

MEASLES:

Measles vaccine, Live, Attenuated IS required if born after 1957. Last dose must be since 1980.

Date_______________________________

Type (circle):

MMR

M.D. Printed Name

__________________________________________________

CLINIC STAMP

M.D. Signature

__________________________________________________

***(OPTIONAL)*******(OPTIONAL)******(OPTIONAL)*******(OPTIONAL)*******(OPTIONAL)***

3. Tetanus Toxid – Date of last series or booster ______________________________ 4. Meningococcal Meningitis Vaccine – Date_______________________________

5. Hepatitis B Series – Dates of Series _____________________________________________________________________________________________________________

In the event this documentation is not easily obtainable, all of the above services can be provided at the Auburn University Medical Clinic for a fee

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