Hepatitis B/Meningitis Waiver 2011 (PDF)

If you are over the age of 18, you will complete this requirement the first time you register for classes when the prompt occurs.           

Religious Exemption (docx)

Requires Notary Authorization.

Medical Waiver (docx)

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.

Submit and follow up with the Registrar's Office.

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 (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  (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 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 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.