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Forms

Hep B Meningitis Waiver

Hepatitis B/Meningitis Immunization History Form (PDF)

If you are over 18, you will complete this form online at the time of your orientation. Do not submit a paper form.       

Religious Exemption

Religious Exemption (docx)

Requires Notary Authorization.

Medical Waiver

Medical Waiver (docx) fax form and signed medical statement to: 423-439-4560

Release

Release of Medical Information (docx)

This must be completed before we can fax or mail any information to the patient or third party, at the request of the patient.

Costs apply depending on the number of pages you are requesting, please call for an exact price 423-439-4225. Prepayment is required!  Please allow 2 weeks for processing, and any information will only be sent to ONE address.

 

Immunization Waiver for Online Classes ONLY

Submit and follow up with the Registrar's Office.

Immunization One-time Waiver (Full-time)

Only first time students at ETSU who are missing either the Varicella 2 or MMR 2 are elgible. Submit and follow up with the Registrar's Office.

Medical History

Medical History (docx)

This is needed for first time patients, patients who have not been to the clinic since the EHR implementation, or whose information may have changed. This form can be filled out easily in Microsoft Word.

Patient Information Form

Patient Information Form  (docx)

This is needed for first time patients, patients who have not been to the clinic since the EHR implementation, or whose information may have changed. This form can be filled out easily in Microsoft Word.

HIPAA

HIPAA Authorization (docx)

This is needed for first time patients, patients who have not been to the clinic since the EHR implementation, or whose information may have changed.

Privacy Information Protected

Privacy Policy Information (docx)

This is needed for first time patients, or patients who have not been to the clinic since the EHR implementation, or whose information may have changed.

2016 imm form

Immunization Form (pdf)

All students please submit this form at least 30 days prior to your orientation/registration date to ensure you will be able to register for your desired classes.  

International Students must have this Immunization Certificate completed in English and signed by a licensed medical provider.

This is the preferred immunization form to expedite immunization processing.

 

 

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