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Division of Academic and Student Affairs 
Campus Health

Patient Forms and Resources

Going to College with Diabetes

Going to College with Asthma

Going to College with Food Allergies

    Advance directives are legal documents in which you give written instructions about your health care if, in the future, you cannot speak for yourself. 

    You can go to one of the following websites to learn more about Advance Health Care Directives and to obtain and complete the forms. If you decide to complete the forms, please bring a copy to our Medical Records so it can be placed in your records.

    Campus Health encourages everyone to have an advanced directive.

    This form is for new patients of the Campus Health Allergy and Immunotherapy Clinic. Before your first appointment, your allergist must complete this form. Bring the completed form, your allergist’s papers and your serum with you to your first allergy appointment at the Campus Health Center.

    Please review the Allergy Injection Program Participant Contract prior to receiving injection at the Campus Health Services Allergy Clinic. If you agree to the terms of this contract, please print and sign your name. If you have questions about this contract, these terms will be reviewed during your first allergy clinic visit.

    All Health Record Forms

    Authorization to Release Protected Health Information [PDF]
    If you would like to give written permission for the release of your medical records to others, complete this form and attach a copy of a picture ID.

    Instructions for Completing the NC State Authorization to Release Protected health Information (PHI) [PDF]

    Health History Form
    If you are new to NC State, log in to HealthyPack Portal to complete this form online. Click the Forms tab at the top of the page. Click Health History Form. Please answer the questions honestly and to the best of your knowledge.

    NC State Immunization Record Form [PDF]
    The Immunization Record Form is designed to collect information about your current immunization status. If you do not have a personal immunization record, the form above can be used in place of your personal immunization record. The record must have a medical provider’s name and address or clinic stamp with provider name and address. You should make and keep a copy of your form for future reference. Please do not submit originals. Please complete and return this form BEFORE you arrive on campus. North Carolina public law requires that you submit proof of your immunizations to the Campus Health Center within 30 days of registration of classes at NC State University. The North Carolina Department of Health and Human Services answers questions about college and university immunization requirements.

    Medical Exemption Forms
    The Commission for Health Services shall adopt by rule medical contraindications to immunizations required by G.S. 130A-152. If a physician licensed to practice medicine in this state certifies that a required immunization is or may be detrimental to a person’s health due to the presence of one of the contraindications adopted by the commission, the person is not required to receive the specified immunization as long as the contraindication persists. The state health director may, upon request by a physician licensed to practice medicine in this state, grant a medical exemption to a required immunization for a contraindication not on the list adopted by the commission.

    Notice of Privacy Practices [PDF]
    This document describes how your medical information may be used and/or disclosed, and how you can access your medical information.

    Parental/Guardian Consent for Treatment of a Minor Form [PDF]
    This form is for parents/guardians whose student(s) are under age 18. Complete this form in order to authorize Campus Health to provide medical services for students under 18.

    Summer Camp Consent [PDF]
    This form is for use by the parents/guardians of minors attending camp activities on campus. University departments and/or camp organizers may download this form to share with parents/guardians or direct them to this site to download the form.

    University-sponsored Health Insurance Plan Waiver Form [online form]
    If you wish to waive the university-sponsored Health Insurance Plan, then complete the online form on Student Blue’s website.

    University-sponsored Health Insurance Plan Enrollment Form [online form]
    If you wish to enroll in a university-sponsored Health Insurance Plan, then complete the online form on Student Blue’s website.

    University-Sponsored Mandatory and Voluntary Health Insurance Plan Benefits [PDF]
    This includes all of the information regarding the benefits and exclusions of the school policy.

    Occupational Medicine Exam Request Form and Authorization for Release of Medical Information
    This form is for university employees and students whose jobs either require or recommend medical surveillance.

    Faculty and Staff Occupational Medicine Exam Request Form

    Faculty and staff must complete this form before work-related travel so their departments can be billed for associated fees.

    Students, please register online with the travel clinic 6 to 8 weeks before you plan to travel. For more information about appointments and travel, visit the Travel Clinic page.

    If you are an NC State student worker who has suffered a job-related injury, please visit the University Worker’s Compensation page.