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Patient Forms

If your TB Risk Screening shows you to be at higher risk based upon your responses on the High Risk TB Screening Questionnaire (found online on the WH&CS Student Health Portal), then you will need to have further testing completed by your Primary Care Provider or other licensed healthcare provider.

  • Download the TB Health Assessment Form and take it to your Primary Care Provider or other licensed healthcare provider who is unrelated to you.
  • Once any additional TB testing is complete and your physician or other licensed healthcare provider has determined that you are free of active TB, the provider must complete and sign the form.
  • Logon to the secure Wellness, Health & Counseling Services (WH&CS) Student Health Portal and upload the completed and signed TB Health Assessment Form for submission to SHC.

Students who do not show risk factors for TB as indicated by their responses on the High Risk TB Screening Questionnaire are not required to complete/submit a TB Health Assessment Form to the Student Health Center.

This form is used to request a medical exemption if a required vaccine is not advisable due to a medical condition. Download the form and have it completed by a licensed physician unrelated to you. The form can be emailedfaxed, or mailed to Student Health Center, Attn: Medical Records. If you need assistance in completing the exemption form, please call (949) 824-5304 to make a Nurse Clinic appointment and one of our nurses can assist you. Please note that exemptions from UC's immunization requirements are no longer permitted for personal or religious beliefs.

This form should be completed by the parent of any student who is not yet 18 years old at the time they arrive on campus. By having authorization to treat a student on file, students who are still 17 years of age may seek treatment at Student Health without significant delays.

This form is used to authorize the release of medical information from Student Health Center to a third party - not to the patient. Please note that charges may apply.

Note: This form is for the release of information from Student Health Center only. Release of information from your insurance carrier may require a separate form which you may obtain from the insurance carrier directly.

This form should be completed by the patient prior to a Women's Health Exam. The patient should bring the completed form with them to the exam.

Visit UC Irvine Health’s website for information regarding Advance Care Planning and Advance Health Care Directives.

Please use this form to notify us of any service related complaint, compliment, question or concern. You may complete and submit this form anonymously if that is your preference. Completed forms can be mailed or faxed to the SHC at the address or fax # noted below, or dropped in the designated Service Issue box in the lobby of the SHC. DO NOT EMAIL this form as it may contain protected personal and/or health information.

501 Student Health Irvine, California 92697-5200 Attn: Credentialing, Quality and Compliance Dept. Tel: 949‑824‑5301 Fax: 949‑824‑1378

This form is used when charges for services received at Student Health Center by a student, student-athlete, faculty or staff will be authorized by, paid for and recharged by SHC to another UCI department. The services and corresponding recharge to SHC must be authorized by a department official prior to the appointment. Refer to the instructions at the bottom of the form.