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Student Health Services will be closed Saturday-Monday, September 5-7, for the Labor Day Holiday.  We will reopen at 8am on Tuesday, September 8.

If you need care or advice when SHS is closed, click on the "After Hours Care" tab under "For Students" in the dropdown menu above. 

Have a great holiday weekend and GO PIRATES!!!
Forms

Immunization Fax:      (252) 328-4007
Medical Records Fax:  (252) 328-0462
Immunization Record 

The immunization record must be completed and signed by a physician, nurse practitioner, or physician assistant. All information must be legible and vaccine dates must contain month/day/year. Immunization record forms must be returned by fax, mail, or dropped off in person to Student Health Service. For questions about state law mandated vaccinations, please visit our Enrollment Requirements page.

Report of Medical History

The required Report of Medical History form is for the student to self report (or parent to report if the student is under age 18) information regarding medical conditions, allergies, medications, and insurance coverage. Students must complete the Report of Medical History electronically by logging on to Online Student Health and selecting "Medical History" from the left hand menu.

Parental Consent for Treatment of Students Under 18

This form is required and must be on file for any student under 18 years of age. A parent or guardian must sign and fax/mail the form to Student Health Service. Please be sure to include the student's name and ECU Banner ID number on the form.

Medical Record Release Forms
Individual's Request for Access to Protected Health Information

Patients should use this form to have records sent directly to themselves. Please fill in information completely and legibly and indicate how the records are to be sent (fax, mail, pick up, etc). Allow 2-3 business days for records to be sent. There is a charge for medical record copies when releasing them directly to the patient.

Authorization for Use and Disclosure of Protected Health Information

This form should be used if a patient is requesting records be sent to another medical office or other third party entity (insurance, law firm, job site, etc), or for SHS staff to be able to discuss care with parents. Please fill in information completely and legibly. Allow 2-3 business days for records to be sent. There is no charge for records sent directly to another facility from Student Health Service.

Outside Lab Order Form

Students who have outside lab orders from another provider can have their labwork performed conveniently at SHS by appointment. This form should be given to the ordering provider to fill out and sign, or lab orders can be accepted on prescription pad paper or office letterhead. ALL fields are required for SHS to be able to perform the labwork. A copy of the student's insurance card must also be provided. Please fax the form and copy of the insurance card to (252) 328-0462, email to shsmedfax@ecu.edu or bring to the SHS appointment. Please call (252) 328-6841 for more information.