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, or for self-release.
  • 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 woman's exam, pap smear, or birth control consultation.
  • 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.
  • Testosterone Therapy Informed Consent Form
  • Feminizing Therapy Informed Consent Form
  • Acupuncture Consent Form

Counseling Services

  • Counseling Services Informed Consent
  • Referral Guide for Students with the PSU Student Health Insurance Plan (PacificSource)
  • Referral Guide for Students who Waived the PSU Student Health Insurance Plan 

Dental Services


  • FERPA Release Form: Please note, this FERPA Release Form pertains only to the PSU Student Health Information Plan and does not include the release of any protected health information.
  • To submit a claim visit the SHAC insurance claims web page.