Forms

Downloadable Forms to Complete Before Your First Visit

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To help minimize contact we request that you download and complete the following forms before your first visit. Students under the age of 18 need a parent's signature on all forms. After all forms are completed please email them to Rosie Coleman, Medical Records Coordinator at rdcoleman@csudh.edu.  If available, please also email copies of your immunization records for review, you may also bring these records to your first visit.

Other Forms

Please download, fill out and print the appropriate form before coming into the SHC, or email if directed by a SHC staff member.  Email all forms to Rosie Coleman, Medical Records Coordinator at rdcoleman@csudh.edu.

Contraception Forms

Medical Records Request and Release Form

This form must be completed before any medical record will be released.

Immunization Form

Tuberculoisis Screening Forms

Please download, fill out and email the completed form that the front office asks you to fill out to Rosie Coleman, Medical Records Coordinator at rdcoleman@csudh.edu PRIOR TO YOUR APPOINTMENT.


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