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.
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.
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.
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.
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 firstname.lastname@example.org or bring to the SHS appointment. Please call (252) 328-6841 for more information.