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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.

COVID-19 Self Monitoring Logs

Students needing to Isolate or Quarantine due to COVID-19 should use the below self-monitoring logs.

10 Day Isolation Log Information Page

10 Day Isolation Log

14 Day Quarantine Information Page

14 Day Quarantine Log

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.
Meningitis Screening Information and Consent (PDF) Meningitis Vaccine Information Sheet (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.
Charges Statement (PDF)
Notice of Privacy Practices (PDF)
Consent for Treatment (PDF)
*Patients who are 17 years old or younger please Click Here for information on required consent forms.

Student Complaint/Grievance Form
Student Complaint/Grievance Form (PDF)

Release of Information from Medical Records.
Release of Medical Records (PDF)
The form allows you to release Protected Health Information (PHI) from our clinic to another clinic/physician or to yourself.
Complete the form by printing the requested information in a legible format. Submit the form, along with your government photo ID such as your driver's license or passport, in one of the following four ways:

    Bring in the completed form to Student Health Services
    Fax the completed form to (210) 458-4151
    Mail it to Student Health Services, ONE UTSA Circle, RWC 1.500, San Antonio, TX 78249
    Email the completed form to

Allow up to twenty one (21) business days to process your request and a representative will contact you and discuss the fee payment. You may receive the documentation by picking it up or mail; sending the documentation by email in not permitted. Faxing is only permitted when sending to another clinic/physician.


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)