Below are the forms for immunizations as well as health consent forms.

Consent for Health Care Services (In-Person and Telehealth):

https://wellness.luc.edu/login_directory.aspx

*These forms only need to be filled out once.*

 

The following can be downloaded and printed for your use.

Required Forms for Incoming Students:

Immunization History Form

Other forms:

• Authorization to Release Protected Health Information
• Wellness Center Optional Enrollment Form
• Community Provider Report
• COVID Vaccine Consent for Wellness Center
• Wellness Center Consent Form- Health Services (In Person and Telehealth) -Adult
• Wellness Center Consent Form- Health Services (In Person and Telehealth) -Minor
• Wellness Center Patient Confidentiality Agreement
• 2022.Vaccine Medical Exemption Request Form
• Advocacy Consent to Disclose (Release of Information Regarding Advocacy Services) 
• Allergy Injection Consent Form
• Consent to Record