Forms

UHS Adult Assessment Form (PDF)
To be completed by all new patients.

UHS Learning and Accommodation Form (PDF)
To be completed by all new patients.

UHS Pediatric Assessment Form (PDF)
Parents: complete for your child’s first pediatrics visit.

Mental Health Services Intake Form (PDF)
To be completed by all new Mental Health Services clients.

Insurance Information Form (PDF)
Complete this form so UHS can bill your insurance company for your care.

Health Plan Enrollment Form (PDF)
Complete this form if you want to purchase health insurance coverage for your spouse, same-sex domestic partner and/or dependent children 19 or under.

New Student Immunization Form (PDF)
To be completed by all new UMass Amherst students. Deadline is the end of the Add/Drop period.

Travel Medicine Patient Questionnaire (PDF)
To be completed before your Travel Medicine Clinic appointment.

Release of Medical Information Form (PDF)
Complete this if you want UHS to release your medical information to another provider, or if you need copies of your records.

Mental Health Release of Information Form (PDF)
Complete this if you want Mental Health Services to release your information to another provider.

Medical Records Release to UHS (PDF)
Complete this if you want another provider to release your medical information to UHS.

E-mail Information and Consent Form (PDF)
Complete this if you want to use e-mail to communicate with your UHS provider.

Health History & Immunization Form (PDF)
Many camps, conferences and groups require attendees to complete a medical history form. Download a copy here.

Prescription Insurance Information Form (PDF)
If you don’t have your prescription insurance card, complete this form and give it to the UHS Pharmacy.

Contraceptive Order Form (PDF)
Make your selection, then bring the form to the UHS Pharmacy to place your order.