Patient Forms

If your TB Risk Screening shows you to be at higher risk based upon your responses on the High Risk TB Screening Questionnaire (found online on the Student Health Patient Portal), then you will need to have further testing completed by your Primary Care Provider or other licensed healthcare provider.

  • Download the TB Health Assessment Form and take it to your Primary Care Provider or other licensed healthcare provider who is unrelated to you.
  • Once any additional TB testing is complete and your physician or other licensed healthcare provider has determined that you are free of active TB, the provider must complete and sign the form.
  • Logon to the secure Student Health Patient Portal and upload the completed and signed TB Health Assessment Form for submission to SHC.

Students who do not show risk factors for TB as indicated by their responses on the High Risk TB Screening Questionnaire are not required to complete/submit a TB Health Assessment Form to the Student Health Center.

This form is used to request a medical exemption if a required vaccine is not advisable due to a medical condition. Download the form and have it completed by a licensed physician unrelated to you. The form can be emailedfaxed, or mailed to Student Health Center, Attn: Medical Records. If you need assistance in completing the exemption form, please call (949) 824-5304 to make a Nurse Clinic appointment and one of our nurses can assist you. Please note that exemptions from UC's immunization requirements are no longer permitted for personal or religious beliefs.

Please note that you will be required to read and acknowledge the form entitled Patient Consent for Treatment and Acknowledgement of Patient Rights and Responsibilities prior to your initial visit. This form can be electronically signed on the Student Health Patient Portal - "Initial Visit Forms" page or when you check in at the time of your appointment.The Consent to Treat Minor Patient form should be completed by the parent of any student who is not yet 18 years old at the time they arrive on campus. By having authorization to treat a student on file, students who are still 17 years of age or younger may seek treatment at Student Health Center without significant delays. Please note that SHC utilizes health provider student trainees such as fellows, residents and/or student interns, in conjunction with licensed professionals, to deliver services to UCI students.

This form is used to authorize the release of medical information from Student Health Center to a third party - not to the patient. Please note that charges may apply.

Note: This form is for the release of information from Student Health Center only. Release of information from your insurance carrier may require a separate form which you may obtain from the insurance carrier directly.

This form should be completed by the patient prior to a Women's Health Exam. The patient should bring the completed form with them to the exam.

Visit UC Irvine Health’s website for information regarding Advance Care Planning and Advance Health Care Directives.

This form is used by students who are covered by UC SHIP to request a referral to a community mental health provider. The form is submitted to SHC’s Insurance Services department who, in turn, will fax the referral authorization form to the designated provider’s office

Please visit our "Feedback"  page for information and instructions regarding the submission of complaints, compliments, questions or suggestions using this form. Click here.


This form is used when charges for services received at Student Health Center by a student, student-athlete, faculty or staff will be authorized by, paid for and recharged by SHC to another UCI department. The services and corresponding recharge to SHC must be authorized by a department official prior to the appointment. Refer to the instructions at the bottom of the form.