Student Health Services Forms
Immunization Record Form: this form should be completed by your doctor and returned to the Health Center as soon as possible. Failure to submit this form will prohibit you from attending classes in accordance with New York State Law.
Canadian Student Immunization Record Form: this form should be completed by your doctor and returned to the Health Center as soon as possible. Failure to submit this form will prohibit you from attending classes in accordance with New York state law.
Athletic Physical Form: this should be completed by your doctor and returned to the Athletics office. Anyone who wishes to participate in an intercollegiate sport must have this form on file with the College.
Immunization Release Form: this form allows the College to release your health records to you or your designee.
Insurance Waiver and Questionnaire: this form should be completed by student athletes and their parents and submitted to the Athletics Office.
Medical History Form: this form should be completed by the student to supply the Health Center with information regarding the student’s health history.
Meningococcal Meningitis Fact Sheet: important information about Meningitis.
Online Meningitis Response Form: this form can be submitted by the student to notify the Health Center of the date of the Meningitis immunization or to decline the meningitis immunization by signing a waiver.
Contact:
Marsha A. Glose RN-C, BSN, MSEd.
Director of Health Services
Medaille College
18 Agassiz Circle
Buffalo, New York 14214
(716) 880-2112
FAX (716) 884-3460
E-mail: mglose@medaille.edu
