Forms
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 FormOther 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