Forms
Save time! Download and complete these forms:
The following forms are available in PDF format. You’ll need Adobe’s free Acrobat Reader to view or print these documents.
Before Your First Visit
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.
Consent to Treat Minor Patients (PDF)
A parent/guardian must complete this form before UHS can provide medical care for those under 18.
Allergy: Immunotherapy Guidelines (PDF)
Your allergist's office must complete and return this form before the UHS Allergy Clinic can administer treatment.
Allergy: Clinic Intake Form (PDF)
To receive treatment at the UHS Allergy Clinic, you must complete this form each year.
Insurance
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.
Immunizations
New Student Immunization Form (PDF)
To be completed by all new UMass Amherst students. Deadline is the end of the Add/Drop period.
Release of Information
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.
Medical Records Release to UHS (PDF)
Complete this if you want another provider to release your medical information to UHS.
Release of Mental Health Information Form (PDF)
Complete this if you want Mental Health Services (MHS) to release your information to another provider or if you want another provider to release your information to MHS.
E-mail Information and Consent Form (PDF)
Complete this if you want to use e-mail to communicate with your UHS provider.
For Camps, Conferences & Groups
Health History & Immunization Form (PDF)
Many camps, conferences and groups require attendees to complete a medical history form. Download a copy here.
Pharmacy
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.
