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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 Records Forms
Individual Request for Protected Health Information

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.

Authorization for Use and Disclosure of Protected Health Information

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.