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Student/University Health Services

College of Nursing

Hep B Meningitis Waiver

Hepatitis B/Meningitis Immunization History Form (PDF)

This form is for legal purposes only.  Completion of this form does not constitute submission or refusal of receiving required vaccinations. 

You will be required to submit your Meningococcal vaccine separately if under 22 and living on campus. 

If you are under 18, a parent or guardian must complete and submit this form for you.  You cannot register without this form on file. 

Over 18, you will complete this form online at the time of registration for classes at 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 Form.

Immunization Waiver (online) 

For Online Classes ONLY. Submit and follow up with the Registrar's Office.

Form

Immunization Waiver (doc) 

For Online Classes ONLY. Submit and follow up with the Registrar's Office.

Online form

Immunization One-time Waiver (online)

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

Forms

Immunization One-time Waiver (pdf)

Only first time students at ETSU who are missing either the Varicella 2 or MMR 2 are eligible. 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

HIPAA Notice of Privacy Policy Practices (pdf)

This Notice describes how medical information about you may be used or disclosed and how you can get access to this information. Please review it carefully.

 

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