Forms

Below are some of the available forms for University Health Services.

Patient Rights and Responsibilities

Immunization Form

UO Certificate of Immunization Status

Dental Clinic Forms

University Health Services Dental Clinic Patient Registration Form

Consent to Bill Dental Insurance

Dental History Form

Medical History Form

Medical Records

Translated forms are provided for reference only. The English language versions must be used when submitting forms to health services.

Release of Information

• Release of Information–Arabic
• Release of Information–Chinese
• Release of Information–Japanese
• Release of Information–Korean

Notice of Privacy Practices (NPP)

• Notice of Privacy Practices–Arabic
• Notice of Privacy Practices–Chinese
• Notice of Privacy Practices–Japanese
• Notice of Privacy Practices–Korean

Consent to Treat

• Consent to Treat–Arabic
• Consent to Treat–Chinese
• Consent to Treat–Japanese
• Consent to Treat–Korean

Informed Consent for Psychiatry Services

International Student Insurance Compliance Form

• Insurance Compliance Form–Arabic
• Insurance Compliance Form–Chinese
• Insurance Compliance Form–Japanese
• Insurance Compliance Form–Korean

Travel Clinic Forms

Pre-Travel Worksheet

Student Travel Guidelines

Forms for Students Under 18 Years Old

Billing Consent Form

Request for Waiver

UO Health Plan Enrollment—Domestic students

UO Health Plan Enrollment—International students

Translations of Common Medical Terms

Arabic

Chinese