Health History, Physical and Immunization Form
It Is The Law: The Pennsylvania State Legislature passed a meningitis vaccination law in 2002 pertaining to students residing in residence halls. This legislation requires that all students residing in a residence hall in Pennsylvania be vaccinated for meningococcal meningitis before moving onto a college campus unless they have signed a waiver after receiving information about the disease and the benefits of the vaccine.
Teleheath Consent Form
You must consent, using this form, in order for us to give you a telehealth or telemedicine session.
To obtain your records please follow the instructions below:
- Print and complete the following form: Medical Records Release Form. Be specific with your request as this is the only information that can be sent.
- Fax the completed form to 570-961-4735.
- Send a note via e-mail to firstname.lastname@example.org with a notation in the subject line medical records request.
- Your records will be e-mailed to you within two weeks.
Before turning your records over, be sure to make copies for your personal file.