We recommend that these forms are typed and completed before your clinic visit. Only complete the forms that correspond to the nature of your visit. We accept original handwritten signatures only (if signatures are needed). Always bring your UTSACard each time you visit the clinic. If you have an insurance card, please bring it with you.
To fill out forms for Tuberculosis Screening and immunizations using the Patient Portal Click Here
Form to be completed prior to a Tuberculosis screening.
Tuberculosis Questionnaire (PDF)
Forms to be completed prior to receiving immunizations.
Bacterial Meningitis Screening Information and Consent (PDF)
Influenza Screening Information and Consent (PDF)
Tdap Screening Information and Consent (PDF)
Forms to be completed if you are visiting the clinic for the first time.
Notice of Privacy Practices (PDF)
Consent for Treatment (PDF)
*Patients who are 17 years old or younger must have this form completed and signed by a parent/guardian prior to the start of classes.
Student Complaint/Grievance Form
Student Complaint/Grievance Form (PDF)
Release of Information from Medical Records.
Release of Medical Records (PDF)
These forms allow you to release Protected Health Information (PHI) from our clinic to another clinic or from another clinic to Student Health Services and release records to yourself. Complete the appropriate form by either typing in the fields or printing it out and writing clearly. Fax the completed form to (210) 458-4151 or mail it to Student Health Services. Allow up to fifteen business days to process your request and a representative will contact you and discuss the fee payment.
Cost: There is a $5.00 charge for pages 1-5 (single page or 5 pages) and then $1.00 per page from page 6 to page 20. Fifty cents per page after page 21. When released to a clinic or physician the fee is waived.
Complete this form prior to a Well Women's Clinic appointment.
Women's Clinic Health History Intake Form (PDF)
Self Screening Tool (PDF)