Forms

Immunization Forms

• Hepatitis B/Meningitis Immunization History Form

  Parents/Guardian use this form if your student is under 18, please complete and submit this form for your student.  Your student cannot register without this form on file. 

  Note to parents: When filling out the online form, please create your own account. DO NOT use your child's ETSU logins. If you do, their name will appear on the signature line instead of yours. 

   

  If you are in a program where your advisor is the one to register you for classes, please submit this Hep B/ Meningitis History to the University Health Center.

   

  Online: Hepatitis B/Meningitis Immunization History Form 

  PDF: Hepatitis B/Meningitis Immunization History Form

  This form is for legal purposes only.  Completion of this form does not constitute submission or refusal of receiving required vaccinations. 

  This form does not exempt you from the Meningococcal vaccine if you plan to live on campus.  You will be required to submit your Meningococcal vaccine separately if under 22 and living on campus.

• ETSU Immunization Form

  It is highly recommended the Immunization Form be received 30 days prior to your on campus orientation or registration. Failure to do so may impact your ability to register for classes.

  PDF:  ETSU Immunization Form

Waivers/Exemption Forms 

• Online Only Immunization Waiver

  This is for students who are taking online classes only and will not be attending any part of their class on campus. Once you have submitted the waiver to the Registrar's Office, an email will be sent to your ETSU email account when your student account has been updated.

  Online Only Immunization Waiver

  Please note: This waiver will need to be completed every semester you plan on being an online only student prior to registering for that semester.  

• One Semester Immunization Waiver

  Only new first time students who are missing either the Varicella 2 and/or MMR 2 are eligible. If you received this exemption at another Tennessee school and are transferring in, you would not be eligible for this waiver. 

  If you qualify for this exemption and have submitted the waiver form to the Registrar's Office, then submit your proof of receiving your second vaccine(s) in 30 days to the University Health Center.

  Online: One Semester Immunization Waiver

• Medical Waiver

  If you have a medical condition or situation preventing you from receiving the required immunizations, complete this form and fax it along with a signed medical statement to 423-439-4560.

  PDF: Medical Waiver

• Religious Exemption

  If receiving the required immunizations goes against any of your religious beliefs or tenants please complete the form below. It will require notary authorization and the original form must be submitted to the University Health Center. 

  PDF: Religious Exemption

Patient Forms

•  Patient Paperwork

  These are fillable PDF documents that can be emailed to the Unviersity Health Center prior to your scheduled appointment. If you are a new ETSU student and would like to have the paperwork on file in case you need to be seen here during your time at ETSU, please complete and submit the "New Patient Paperwork". If you have insurance, please provide a photocopy of the front and back of the insurance card to have on file as well. 

  PDF: Not Available At This Time

• Permission to Treat 

  This PDF will need to be printed, signed, and emailed to the University Health Center by the partent/guardian of the patient if the patient is under the age of 18 years old. This form will need to be submitted before the patient's scheduled appointment time. 

  PDF: Permission to Treat Form

• Medical Release Form

  This must be completed before we can fax or mail any information to the patient or third party, at the request of the patient. Fax the medical release form to 423-439-4560 or email it to the University Health Center.

  Costs apply depending on the number of pages you are requesting. Prepayment is required! 

  Please allow 10 business days for processing, and any information will only be sent to one address. 

  PDF: From Outside Provider to ETSU University Health Center

  PDF: From ETSU University Health Center to Outside Provider

• Email Consent Form

  Complete this form if you would like to have your medical records emailed to you. Make sure you have also completed the medical release form above.

  Fax the email consent form and medical release form to 423-439-4560 or email it to the University Health Center.

  PDF: Email Consent Form

• HIPAA Notice of Privacy Policy Practices

  This Notice describes how medical information about you may be used or disclosed and how you can get access to this information. Please review it carefully.

  https://www.etsu.edu/universitycounsel/hipaa/privacy-practices.php