• Student Health Services
    A Division of Student Affairs

Forms

DoctorThe 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.
  • Housing Meningitis Requirement (students living on-campus ONLY)
    Beginning with the Fall 2013 term, all students under age 22 who are enrolling in a TBR institution for the first time regardless of the level at which the student is matriculating AND who will be living in on-campus housing, must show proof of adequate immunization against meningitis prior to moving into on-campus housing. “Adequate Immunization” means students must have been vaccinated on or after their 16th birthday. On move-in day, those students who have not previously provided such proof must provide it before they can be allowed to move in.
  • Meningitis/Hepatitis B Acknowledgement
    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.
  • Request for Exemption from Immunizations For Religious Reasons
    This form is required if you would like to request an exemption from the immunization requirement because it conflicts with your religious beliefs and practices.