Student Health Center

Health Center Forms

  • Certificate of Immunization for College Students (submit only when filing an Exemption)
    If you are filing a Statement of Exemption to Immunization, please fill out the bottom of page 1 on the above form and submit to the Health Center office.
     
  • Authorization to Release Health Information from FLC
    If you are requesting a copy of your immunization records please attempt to locate your original record before contacting us. If you are unable to obtain your original record you may request a copy from us by submitting the form above. Please allow 3-7 days to process your request. We will scan and email the record back to you and you will be responsible to forward this to the appropriate facility.
     
  • Authorization to Release Health Information to FLC
    The above form is to request information to be sent from your physician to Fort Lewis College. Fill out this form and email or fax to the Health Center to have medical information sent to Fort Lewis College (such as immunization records).
     
  • Notice of Privacy Practices (HIPPA)
    This notice describes how medical information about you may be used and disclosed, and how you can get access to your information. Review it carefully and sign the bottom of the form. Detailed version.

 

Forms may be emailed or faxed to the Health Center office:

Email
Fax: (970) 247-7621