Search Google Appliance


Download Forms

You will need Acrobat Reader to view some of the forms below. Click here if you need to download Acrobat Reader.

Measles Vaccine Requirement

Health Services

  • Health History Form (form only necessary at time of appointment): Please fill out this form, print it, and bring it with you to SHAC before your first medical visit. This form will need to be updated once a year.
  • Health Services Consent Form: This form is required before health services can be rendered at SHAC. It contains information on your patient rights and responsibilities, along SHAC hours of operation, billing practices, our health philosophy, and the state Measles and Mumps requirement.
  • Authorization of Release: Please complete this form if you need to authorize your medical and/or mental health records to be released or discussed with an outside provider. Records are released free of charge from provider to provider for continued care. If records are requested to be released to the individual there will be a fee based on the complexity of preparation. This fee will be billed to the student's account.
  • Nutrition Forms
  • Women's Health History: Please complete the Women's Health History Form and bring to SHAC if your appointment is with a provider for a women's exam, pap smear, or XYZ.
  • Sexual Health History: Please complete the Sexual Health History Form and bring to SHAC if your appointment is with an Registered Nurse or medical provider, for a screening for Sexually Transmitted Infections (STI) or for STI symptoms.

Counseling Services

Dental Services

  • Authorization of Release: You may fill out the form and submit it to the Dental Office (UCB Suite 309), or fill it out electronically and email it to dental@pdx.edu. Please note that email is not a secure form of communication.

Insurance