Forms
Commonly used forms in the Student Health Center.
Minor Consent to Participate in Telemedicine Consultation/Treatment (pdf)
Authorization for Telehealth Treatment
Consent For Treatment Of A Minor Who Does Not Have Legal Power To Consent (pdf)
Students under the age of 18 must have a Consent for Treatment Form signed by parent or legal guardian. All forms must be notarized and mailed to the Student Health Center. The mailing address for the SHC can be found on the homepage.
Consent for Treatment Form (pdf)
Students over the age of 18 can consent to own medical treatment
Consent for Minor To Own Treatment (pdf)
You must be living apart from your parents or guardian and be managing your own finances
Authorization to Release Medical Records from UT Dallas (pdf)
The Student Health Center maintains a patient’s medical records for 10 years from the date of last visit. Medical records are destroyed after 10 years.
Authorization to Release Medical Records to UT Dallas (pdf)
The Student Health Center maintains a patient’s medical records for 10 years from the date of last visit. Medical records are destroyed after 10 years.
Bacterial Meningitis Vaccine Requirement Form (pdf)
To learn more, visit the Registrar’s Vaccination Requirement page.
Patient Rights and Responsibilities (pdf)
Student Health Center Patient Rights
Patients Conduct and Responsibilities
Health History Questionnaire (pdf)
Completion of this form will help your health care provider get an accurate history of your medical concerns and conditions.
Off-campus TB Screening Form (pdf)
Off Campus TB Testing Locations (pdf)
Tuberculosis (TB) screening is required for all persons born outside the United States, regardless of the status of their application.
Allergy Injection Policy (pdf)
Allergy Injection Orders (pdf)
The University of Texas at Dallas Student Health Center (UTD SHC) is pleased to administer allergy injections to our students who are under an immunotherapy regimen prescribed by their physicians.
