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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

Division of Student LifeDivision of Student Life

  • Division of Student Life
  • University Career Center
  • Office of the Dean of Students
  • Erb Memorial Union
  • Holden Center for Leadership and Community Engagement
  • Department of Physical Education and Recreation
  • Parent and Family Programs

Student Services

  • Office of Financial Aid and Scholarships
  • Office of the Registrar
  • University Counseling Services
  • University Health Services
  • University Housing
  • University Testing Center
University Health Services
1590 E 13th Ave
Eugene , OR 97403
University Health Services Building

P: 541-346-2770 F: 844-965-9250

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© University of Oregon.   All Rights Reserved.

UO prohibits discrimination on the basis of race, color, sex, national or ethnic origin, age, religion, marital status, disability, veteran status, sexual orientation, gender identity, and gender expression in all programs, activities and employment practices as required by Title IX, other applicable laws, and policies. Retaliation is prohibited by UO policy. Questions may be referred to the Title IX Coordinator, Office of Investigations and Civil Rights Compliance, or to the Office for Civil Rights. Contact information, related policies, and complaint procedures are listed on the statement of non-discrimination.

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