For your convenience, download and print these forms prior to your visit. Please complete the forms and bring them to your appointment.
Note: UTHS forms and Vaccine Information Statements are in PDF format and can be downloaded and printed. If you do not have Adobe Acrobat Reader, you can download and install a copy from Adobe's Web site.
|Medical Records Request||New Employee/Visitor Health History Questionnaire|
|Patient History||Clinic Registration|
|Occupational Health Program Enrollment||First Report of Injury|
|Pre-Travel Health Consultation||Financial Disclosure Form-Travel|
Vaccine Information Statements (VIS) are information sheets produced by the Centers for Disease Control and Prevention (CDC) that explain to vaccine recipients, their parents or their legal representatives the benefits and risks of a vaccine. Please bring your shot records with you.
*Please note that insurance may not cover vaccines listed below.
|Anthrax - Administer Only||Polio|
|Hepatitis A (Series of 2)||Rabies (Series of 3)|
|Hepatitis B (Series of 3)||Shingles (Herpes Zoster)|
|Human Papillomavirus (HPV) (Series of 3)||Tetanus/Diphtheria/A-cellular Pertussis (Tdap)|
|Japanese Encephalitis (Series of 2)||Typhoid|
|Measles/Mumps/Rubella (MMR)||Varicella (Chickenpox) (Series of 2)|