Forms

The following forms are available online in PDF format. To view, complete and print these forms, you must have Adobe Reader installed on your computer. It is free from www.adobe.com . Alternatively, a print version of the following forms are available at Student Health Services.

• Authorization to Disclose Health Records
  Must be completed by any student wanting to have medical records sent from MTSU to another organization (use Sending form) or wanting to have medical records sent to Student Health Services at MTSU (use Receiving form).
• Varicella and MMR Certificate of Immunization
  Must be completed and signed by a licensed M.D. or D.O. and returned to MTSU Student Health Services. When an entering full-time student is born after 1979, the Varicella section must be completed and submitted before registering for classes at MTSU. W hen an entering full-time student is born after 1956, the MMR section must be submitted before registering for classes at MTSU. Please disregard the form if you were born before 1957, if you are attending part-time, or if you have graduated from a Tennessee public high school in 1999 or later.
• Meningitis/Hepatitis B Waiver Form
  Must be completed by all new undergraduates and graduate students. For students under the age of 18 the form must be printed out, signed by a parent or legal guardian and sent to MTSU Health Services. For students over the age of 18 sign on to PipelineMT and complete the form online.
• Instructions for New Allergy Patients
  To be printed and signed then brought in to Student Health Services by new allergy patients along with their allergist's instruction sheet with extracts.