JUNIATA COLLEGE STUDENT HEALTH INFORMATION SHEEET

(To be completed by student)

_______________________________________________           ___________        __________________        _____      _________

 Last Name                               First name         DOB              Student SSN            Sex    Class

____________________________________________________          (____)__________

Street Address               City/Town                               State       Zip            Home Phone

_________________________________________________________________________

Parent/Guardian                         Address                

 

(_____)_____________      (______)______________    (_____)_______________

Home Phone                           Business Phone                       Cell Phone

                      

________________________    (______)_______________  (_____)_______________

Emergency contact (other than parent) Home Phone                          Business Phone

 

INSURANCE INFORMATION - **Attach a copy of your insurance card (front and back) for our records.**  The student should also carry his or her own insurance card with them while they are at school. 

Subscriber’s name___________________________     Relationship to student_____________

**If prior approval is needed for lab work, referrals or hospitalizations, please provide the student with the necessary information so he/she can get approvals.  The Health Center is not responsible for obtaining prior authorizations and approvals.

                 

HEALTH INFORMATION

Chronic health problems, disabilities, special needs___________________________________

________________________________________________________________________

Current medications_________________________________________________________

Do you have any allergies to medication? Yes ____  No____ List______________________________________________

Do you have any other allergies? Yes____ No_____ List_____________________________________________________

 

CONSENT FOR MEDICAL CARE – for parents/guardians of applicants under 18 years of age only

I, _______________________, as parent/guardian of_________________________  

(print your full name)                                                    (print student’s full name)

do hereby authorize the staff at the Juniata College Health & Wellness Center to provide routine medical care to my child.  This may include ordering lab tests, performing physical exams, treatment of minor illnesses and injuries, and administering immunizations.  I also authorize the Center staff to seek emergency medical care if necessary.

I understand that this authorization may be revoked, in writing, at any time.

 

 

**Please note:  Your health record will be kept on file at the Health & Wellness Center for seven years after graduation, at which time it will be destroyed.