The Report of Medical History 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.
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.
Use this form if you are a patient requesting your Student Health records be sent directly to you personally. Please fill in information completely and legibly. Indicate whether you would like your records sent to you by fax, mail, or if you will be picking up your records in person. Allow 2-3 business days for your records to be ready. There is a charge for medical record copies when releasing them to an individual.
This form should be used if a patient is requesting his/her Student Health records be sent to another medical office or other third party entity (insurance, law firm, job site, etc), or if requesting a release for SHS 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 if records are directly sent to another facility from Student Health Service.
Students seeking withdrawal from all classes due to medical reasons must fill out sections 1, 2 and 7 of the medical withdrawal form. This form must be submitted to the administrative assistant at Student Health Services via fax, mail, e-mail attachment or in person, along with a letter from the student explaining why a withdrawal is being sought. In addition, students should fill out the release form below so Student Health Services can contact professors regarding the withdrawal. Once the forms have been submitted, the student should call to make an appointment with the Student Health Services Director, Jolene Jernigan, to discuss the withdrawal and to receive approval or denial of the request.
This form allows Student Health Services to discuss your withdrawal request with your professors. Input from your professors concerning class attendance, overall performance and communication regarding missed classes is necessary when approving or denying requests for medical withdrawals. Please fill out this form and return it along with the other necessary withdrawal documents described above to the administrative assistant at Student Health Services.
