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0.00 Tc 1 0 0 1 20.88 443.16 Tm <494E535552414E434520> Tj /F3 7.5 Tf 1 0 0 1 70.92 443.52 Tm <494E464F524D4154494F4E> Tj /F3 13.5 Tf 1 0 0 1 132.12 434.88 Tm <744E737552416D20> Tj /F3 9.0 Tf 1 0 0 1 364.32 435.96 Tm <6375414D4E546F52534D4D4558506172656E7420> Tj /F3 7.5 Tf 1 0 0 1 478.44 437.04 Tm <796F7520> Tj /F3 7.0 Tf 1 0 0 1 493.56 436.68 Tm <61726520> Tj /F3 7.5 Tf 1 0 0 1 506.16 436.68 Tm <696E737572656120> Tj /F3 7.0 Tf 1 0 0 1 533.88 436.68 Tm <756E6F654F> Tj 0.00 Tc /F3 7.5 Tf 1 0 0 1 129.96 407.16 Tm <506F6C696379686F6C64657220> Tj /F3 13.5 Tf 1 0 0 1 175.68 407.16 Tm <442E4F2E422E20> Tj /F3 7.5 Tf 1 0 0 1 291.96 407.88 Tm <506F6C697179686F6C64657220> Tj 1 0 0 1 336.60 407.88 Tm <535323> Tj 0.00 Tc /F3 8.0 Tf 1 0 0 1 21.24 387.72 Tm <6C6E737572656420> Tj /F3 7.5 Tf 1 0 0 1 50.40 387.36 Tm <6F6172656E74277320> Tj 1 0 0 1 81.00 388.08 Tm <61646472657373> Tj 0.00 Tc /F3 8.0 Tf 1 0 0 1 114.12 379.08 Tm <41646472657373> Tj 0.00 Tc 1 0 0 1 533.16 380.88 Tm <7A6970> Tj 0.00 Tc /F3 7.5 Tf 1 0 0 1 328.68 380.16 Tm <43697479> Tj 0.00 Tc 1 0 0 1 446.40 380.88 Tm <5374617465> Tj 0.00 Tc 1 0 0 1 21.60 359.64 Tm <496E737572656420> Tj 1 0 0 1 50.76 360.36 Tm <706172656E747320> Tj /F3 8.0 Tf 1 0 0 1 79.20 360.72 Tm <70686F6E6520> Tj /F3 7.5 Tf 1 0 0 1 104.04 360.36 Tm <6E756D626572> Tj /F3 8.5 Tf 1 0 0 1 21.60 331.92 Tm <504F4C49435923> Tj 0.00 Tc /F3 7.5 Tf 1 0 0 1 237.24 333.36 Tm <47524F555020> Tj /F3 8.0 Tf 1 0 0 1 267.84 333.72 Tm <23> Tj 0.00 Tc /F3 8.5 Tf 1 0 0 1 21.24 314.28 Tm <284E6F74653A20> Tj /F3 7.5 Tf 1 0 0 1 47.88 313.56 Tm <5468697320> Tj 1 0 0 1 65.52 313.56 Tm <696E6C6F726D6174696F6E20> Tj /F3 9.0 Tf 1 0 0 1 106.56 313.92 Tm <77695B20> Tj /F3 7.5 Tf 1 0 0 1 120.60 314.28 Tm <6E6F7420> Tj 1 0 0 1 133.56 314.28 Tm <626520> Tj 1 0 0 1 144.72 314.28 Tm <7573656420> Tj 1 0 0 1 163.80 314.28 Tm <666F7220> Tj 1 0 0 1 175.68 314.64 Tm <616E7920> Tj 1 0 0 1 190.80 315.36 Tm <707572706F736520> Tj 1 0 0 1 221.76 314.64 Tm <6F7468657220> Tj 1 0 0 1 241.56 314.64 Tm <7468616E20> Tj 1 0 0 1 259.20 314.64 Tm <746F20> Tj /F3 7.0 Tf 1 0 0 1 268.20 315.00 Tm <62696C6C20> Tj /F3 7.5 Tf 1 0 0 1 279.72 315.00 Tm <6170706C696361626C6520> Tj 1 0 0 1 317.88 315.00 Tm <6865616C746820> Tj 1 0 0 1 341.28 315.36 Tm <696E737572616E636520> Tj /F3 7.0 Tf 1 0 0 1 376.92 315.36 Tm <666F7220> Tj /F3 7.5 Tf 1 0 0 1 388.08 315.36 Tm <736572766963657320> Tj 1 0 0 1 419.04 315.72 Tm <726563656976656420> Tj /F3 7.0 Tf 1 0 0 1 451.08 315.72 Tm <617420> Tj /F3 7.5 Tf 1 0 0 1 459.72 315.72 Tm <74686520> Tj 1 0 0 1 473.40 316.08 Tm <554E4320> Tj 1 0 0 1 492.12 316.08 Tm <53747564656E7420> Tj /F3 7.0 Tf 1 0 0 1 520.56 316.08 Tm <4865616C746820> Tj /F3 7.5 Tf 1 0 0 1 544.68 316.08 Tm <43656E746572292E> Tj 0.00 Tc /F3 8.0 Tf 1 0 0 1 21.60 288.00 Tm <4D414A4F5220> Tj /F3 7.5 Tf 1 0 0 1 52.56 288.00 Tm <4649454C4420> Tj 1 0 0 1 77.40 288.36 Tm <4F4620> Tj 1 0 0 1 90.36 288.36 Tm <5354554459> Tj 0.00 Tc /F3 8.5 Tf 1 0 0 1 258.84 289.44 Tm <5354414E2753> Tj 0.00 Tc /F3 8.0 Tf 1 0 0 1 258.84 271.08 Tm <4F20> Tj /F3 7.0 Tf 1 0 0 1 267.84 271.08 Tm <46756C6C20> Tj /F3 7.5 Tf 1 0 0 1 282.24 271.08 Tm <74696D6520> Tj /F3 8.0 Tf 1 0 0 1 299.88 271.08 Tm <556E646572677261647561746520> Tj 1 0 0 1 356.76 271.44 Tm <4F20> Tj /F3 8.5 Tf 1 0 0 1 365.76 271.80 Tm <5061642D74696D6520> Tj /F3 8.0 Tf 1 0 0 1 403.56 272.16 Tm <4F20> Tj /F3 7.0 Tf 1 0 0 1 412.56 272.16 Tm <46756C6C20> Tj /F3 7.5 Tf 1 0 0 1 426.96 272.16 Tm <74696D6520> Tj 1 0 0 1 444.60 272.16 Tm <477261647561746520> Tj 1 0 0 1 479.52 272.52 Tm <2D20> Tj 1 0 0 1 484.56 272.16 Tm <44657074> Tj 1 0 0 1 21.60 260.28 Tm <454E544552494E4720> Tj /F3 8.5 Tf 1 0 0 1 65.52 260.28 Tm <53454D455354455220> Tj /F3 10.0 Tf 1 0 0 1 116.28 261.00 Tm <747220> Tj /F3 11.5 Tf 1 0 0 1 125.64 261.00 Tm <46616C6C3230313320> Tj /F3 8.0 Tf 1 0 0 1 173.88 261.36 Tm <4F20> Tj /F3 7.5 Tf 1 0 0 1 182.88 261.36 Tm <537072696E6720> Tj 1 0 0 1 208.44 261.36 Tm <32303134> Tj /F3 13.5 Tf 1 0 0 1 51.48 241.56 Tm <4420> Tj 1 0 0 1 68.76 241.92 Tm <46616C6C327D313420> Tj /F3 12.5 Tf 1 0 0 1 134.64 242.64 Tm <6E20> Tj /F3 7.5 Tf 1 0 0 1 145.80 242.64 Tm <537072696E6720> Tj /F3 8.0 Tf 1 0 0 1 170.64 242.64 Tm <32303135> Tj 0.00 Tc 1 0 0 1 21.96 204.12 Tm <50508056494F555320> Tj /F3 7.5 Tf 1 0 0 1 66.24 204.48 Tm <52454C4154494F4E5348495020> Tj 1 0 0 1 126.00 204.84 Tm <5749544820> Tj /F3 8.0 Tf 1 0 0 1 148.68 205.20 Tm <54484520> Tj /F3 7.5 Tf 1 0 0 1 167.40 205.20 Tm <554E495645525349545920> Tj 1 0 0 1 217.44 205.56 Tm <4F4620> Tj 1 0 0 1 230.76 205.56 Tm <4E4F52544845524E20> Tj 1 0 0 1 276.84 205.92 Tm <434F4C4F5241444F> Tj 0.00 Tc 1 0 0 1 343.80 206.28 Tm <5468697320> Tj 1 0 0 1 361.08 206.28 Tm <696E666F726D6174696F6E20> Tj /F3 7.0 Tf 1 0 0 1 401.40 206.64 Tm <697320> Tj /F3 8.0 Tf 1 0 0 1 408.96 206.64 Tm <73747269646C7920> Tj /F3 7.5 Tf 1 0 0 1 433.44 206.64 Tm <666F7220> Tj 1 0 0 1 444.96 206.64 Tm <74686520> Tj 1 0 0 1 458.64 206.64 Tm <75736520> Tj /F3 8.0 Tf 1 0 0 1 473.40 206.64 Tm <6F7474686520> Tj /F3 7.5 Tf 1 0 0 1 494.64 207.00 Tm <53747564656E7420> Tj /F3 7.0 Tf 1 0 0 1 523.08 207.00 Tm <4865616C746820> Tj /F3 7.5 Tf 1 0 0 1 547.20 207.00 Tm <43656E746572> Tj 1 0 0 1 344.16 196.56 Tm <616E6420> Tj 1 0 0 1 359.28 197.28 Tm <77696C6C20> Tj /F3 7.0 Tf 1 0 0 1 372.60 196.92 Tm <6E6F7420> Tj /F3 7.5 Tf 1 0 0 1 385.20 197.28 Tm <626520> Tj 1 0 0 1 396.00 197.28 Tm <72656C656173656420> Tj /F3 8.0 Tf 1 0 0 1 427.68 197.28 Tm <746F20> Tj /F3 7.5 Tf 1 0 0 1 437.04 197.28 Tm <616E796F6E6520> Tj 1 0 0 1 464.76 197.64 Tm <776974686F757420> Tj /F3 7.0 Tf 1 0 0 1 492.12 198.36 Tm <796F757220> Tj /F3 7.5 Tf 1 0 0 1 508.68 197.64 Tm <6B6E6F776C6564676520> Tj /F3 7.0 Tf 1 0 0 1 547.56 197.28 Tm <616E64> Tj /F3 7.5 Tf 1 0 0 1 344.52 187.92 Tm <7772697474656E20> Tj 1 0 0 1 369.72 187.92 Tm <636F6E73656E742E> Tj 0.00 Tc /F3 10.5 Tf 1 0 0 1 22.32 185.76 Tm <747220> Tj /F3 7.5 Tf 1 0 0 1 32.04 185.76 Tm <50726576696F757320> Tj /F3 10.5 Tf 1 0 0 1 65.52 185.76 Tm <73747564656E7420> Tj /F3 7.5 Tf 1 0 0 1 104.04 186.48 Tm <446174657320> Tj 1 0 0 1 126.72 186.48 Tm <456E726F6C6C6564> Tj 0.00 Tc /F3 8.0 Tf 1 0 0 1 22.68 147.24 Tm <504552534F4E414C20> Tj 1 0 0 1 69.84 147.24 Tm <4845414C544820> Tj /F3 7.5 Tf 1 0 0 1 104.40 147.96 Tm <484953544F5259> Tj 0.00 Tc 1 0 0 1 22.68 120.60 Tm <446F20> Tj /F3 8.0 Tf 1 0 0 1 34.92 121.32 Tm <796F7520> Tj /F3 7.5 Tf 1 0 0 1 50.76 120.60 Tm <6861766520> Tj 1 0 0 1 70.20 120.60 Tm <616E7920> Tj 1 0 0 1 84.96 120.60 Tm <6472756720> Tj 1 0 0 1 103.32 120.96 Tm <616C6C6572676965733F20> Tj /F3 8.0 Tf 1 0 0 1 139.68 121.32 Tm <4F20> Tj /F3 8.5 Tf 1 0 0 1 148.68 121.32 Tm <59657320> Tj 1 0 0 1 167.04 121.32 Tm <4F20> Tj /F3 9.0 Tf 1 0 0 1 176.40 121.68 Tm <4E6F20> Tj /F3 7.5 Tf 1 0 0 1 190.80 121.68 Tm <6C6620> Tj 1 0 0 1 197.28 122.04 Tm <7965732C20> Tj 1 0 0 1 214.20 122.40 Tm <706C6561736520> Tj /F3 7.0 Tf 1 0 0 1 240.12 121.68 Tm <737065636972793A> Tj 0.00 Tc /F3 8.0 Tf 1 0 0 1 22.32 78.84 Tm <41726520> Tj /F3 7.5 Tf 1 0 0 1 37.80 79.56 Tm <796F7520> Tj /F3 8.0 Tf 1 0 0 1 53.28 78.84 Tm <637572656E746C7920> Tj /F3 7.5 Tf 1 0 0 1 85.68 78.84 Tm <74616B696E6720> Tj 1 0 0 1 109.44 79.20 Tm <6461696C7920> Tj 1 0 0 1 127.80 79.56 Tm <6D656469636174696F6E733F20> Tj /F3 8.0 Tf 1 0 0 1 176.76 79.92 Tm <4F20> Tj /F3 9.0 Tf 1 0 0 1 185.76 79.92 Tm <59657320> Tj /F3 8.5 Tf 1 0 0 1 204.48 79.92 Tm <4F20> Tj /F3 10.5 Tf 1 0 0 1 213.84 79.92 Tm <4E6F20> Tj /F3 7.0 Tf 1 0 0 1 230.76 80.28 Tm <6C6620> Tj /F3 7.5 Tf 1 0 0 1 236.88 80.64 Tm <7965732C20> Tj 1 0 0 1 253.80 81.00 Tm <706C6561736520> Tj /F3 7.0 Tf 1 0 0 1 278.64 80.28 Tm <6C69737420> Tj /F3 7.5 Tf 1 0 0 1 289.80 80.28 Tm <74686520> Tj 1 0 0 1 303.48 80.28 Tm <647275677320> Tj 1 0 0 1 325.44 80.28 Tm <616E64> Tj 0.00 Tc /F3 7.0 Tf 1 0 0 1 23.40 30.24 Tm <4F6F20> Tj /F3 8.0 Tf 1 0 0 1 35.64 30.96 Tm <796F7520> Tj /F3 7.5 Tf 1 0 0 1 51.48 29.88 Tm <74616B6520> Tj 1 0 0 1 68.76 30.24 Tm <616C6C6572677920> Tj 1 0 0 1 94.32 30.60 Tm <646573656E736974697A6174696F6E20> Tj /F3 12.0 Tf 1 0 0 1 148.32 30.96 Tm <73686F74733F20> Tj /F3 8.0 Tf 1 0 0 1 187.56 31.32 Tm <4F20> Tj /F3 9.0 Tf 1 0 0 1 196.56 31.32 Tm <59657320> Tj /F3 8.5 Tf 1 0 0 1 215.28 31.32 Tm <4F20> Tj /F3 7.5 Tf 1 0 0 1 224.64 31.32 Tm <4E6F> Tj 1 0 0 1 23.76 11.52 Tm <6C6620> Tj /F3 8.0 Tf 1 0 0 1 30.24 11.16 Tm <736F2C20> Tj /F3 7.5 Tf 1 0 0 1 43.92 11.16 Tm <646F20> Tj 1 0 0 1 54.72 11.88 Tm <796F7520> Tj 1 0 0 1 69.84 11.88 Tm <706C616E20> Tj /F3 8.0 Tf 1 0 0 1 86.76 11.52 Tm <746F20> Tj /F3 7.5 Tf 1 0 0 1 96.12 11.88 Tm <7265636569766520> Tj 1 0 0 1 123.48 12.60 Tm <796F757220> Tj 1 0 0 1 141.12 12.24 Tm <616C6C6572677920> Tj 1 0 0 1 166.32 12.24 Tm <73686F747320> Tj 1 0 0 1 187.92 12.60 Tm <617420> Tj /F3 9.0 Tf 1 0 0 1 196.92 12.60 Tm <554E433F20> Tj /F3 8.0 Tf 1 0 0 1 225.36 12.60 Tm <4F20> Tj /F3 8.5 Tf 1 0 0 1 234.36 12.60 Tm <59657320> Tj /F3 8.0 Tf 1 0 0 1 252.36 12.96 Tm <4F20> Tj /F3 7.0 Tf 1 0 0 1 261.36 12.96 Tm <4E6F> Tj 0.00 Tc 1 0 0 1 323.28 13.32 Tm <666620> Tj /F3 7.5 Tf 1 0 0 1 329.76 13.68 Tm <7965732C20> Tj 1 0 0 1 346.68 14.04 Tm <706C6561736520> Tj 1 0 0 1 371.52 13.68 Tm <636F6E7461636C20> Tj /F3 7.0 Tf 1 0 0 1 398.88 13.68 Tm <53484320> Tj /F3 7.5 Tf 1 0 0 1 416.88 13.68 Tm <666F7220> Tj /F3 8.0 Tf 1 0 0 1 428.76 13.68 Tm <6164766963652E20> Tj /F3 7.5 Tf 1 0 0 1 458.28 14.76 Tm <283937302920> Tj 1 0 0 1 478.80 14.04 Tm <3335312D32343132> Tj ET endstream endobj 6 0 obj << /Type /Font /Subtype /Type1 /BaseFont /Helvetica /Encoding /WinAnsiEncoding >> endobj 7 0 obj << /Length 8 0 R >> stream 2AV UNIVERSITY OF NORTHERN COLORADOHEALTH HISTORY RETURN FORM TO:AV Student Health CenterCassidy HallCampus Box 37Greeley, CO 80639 NAME LAST FIRST MI BEAR # ss# DATE DATE OF BIRTH(mm/ddiyy) GENDEROM OF trT COUNTRY OF BIRTHO U.S. O Other (specify) ADDRESS #1 CITY/STATEZIP HOME PHONE MOBILE PHONE Relationship EMERGENCY CONTACT INSURANCE INFORMATIONtNsuRAm cuAMNToRSMMEXParent you are insurea unoeO Policyholder D.O.B. Poliqyholder SS# lnsured oarent's address Address zip City State Insured parents phone numberPOLICY# GROUP # (Note: This inlormation wi[ not be used for any purpose other than to bill applicable health insurance for services received at the AV Student Health Center). MAJOR FIELD OF STUDY STAN'S O Full time Undergraduate O Pad-time O Full time Graduate - DeptENTERING SEMESTER tr Fall2013 O Spring 2014D Fall2}14 n Spring 2015 PPVIOUS RELATIONSHIP WITH THE UNIVERSITY OF NORTHERN COLORADO This information is stridly for the use otthe Student Health Centerand will not be released to anyone without your knowledge andwritten consent. tr Previous student Dates Enrolled PERSONAL HEALTH HISTORY Do you have any drug allergies? O Yes O No lf yes, please speciry: Are you curently taking daily medications? O Yes O No lf yes, please list the drugs and Oo you take allergy desensitization shots? O Yes O Nolf so, do you plan to receive your allergy shots at AV? O Yes O No ff yes, please contacl SHC for advice. 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459.00 Tm <50657074696320> Tj 1 0 0 1 328.32 459.00 Tm <756C636572> Tj 0.00 Tc /F3 11.0 Tf 1 0 0 1 419.04 460.44 Tm <6E> Tj 0.00 Tc /F3 6.5 Tf 1 0 0 1 307.80 442.44 Tm <50656C76696320> Tj 1 0 0 1 327.60 442.44 Tm <696E6665636C696F6E> Tj 0.00 Tc /F3 11.5 Tf 1 0 0 1 419.04 441.72 Tm <6F> Tj 0.00 Tc /F3 6.5 Tf 1 0 0 1 308.16 425.88 Tm <50686C656269746964626C6F6F6420> Tj /F3 7.0 Tf 1 0 0 1 353.88 425.88 Tm <636C6F74> Tj 0.00 Tc /F3 10.5 Tf 1 0 0 1 419.04 425.16 Tm <7472> Tj 0.00 Tc /F3 6.5 Tf 1 0 0 1 308.16 408.96 Tm <506F6C696F> Tj 0.00 Tc /F3 11.0 Tf 1 0 0 1 419.40 408.24 Tm <6F> Tj 0.00 Tc /F3 6.5 Tf 1 0 0 1 308.16 392.40 Tm <50726373746136746973> Tj 0.00 Tc /F3 10.0 Tf 1 0 0 1 419.40 391.68 Tm <7472> Tj 0.00 Tc /F3 6.5 Tf 1 0 0 1 308.52 375.84 Tm <526865756D6174696320> Tj /F3 7.0 Tf 1 0 0 1 342.00 375.84 Tm <6665766572> Tj 0.00 Tc /F3 11.5 Tf 1 0 0 1 419.40 374.04 Tm <6F> Tj 0.00 Tc /F3 6.0 Tf 1 0 0 1 308.52 356.76 Tm <5365697A75726520> Tj /F3 6.5 Tf 1 0 0 1 332.64 356.76 Tm <6469736F7264657220> Tj 1 0 0 1 359.64 357.48 Tm <286570696C6570737929> Tj 0.00 Tc /F3 11.5 Tf 1 0 0 1 419.40 356.76 Tm <6F> Tj 0.00 Tc /F3 7.5 Tf 1 0 0 1 556.56 559.80 Tm <596573> Tj 0.00 Tc /F3 6.0 Tf 1 0 0 1 450.36 543.24 Tm <536B696E20> Tj /F3 6.5 Tf 1 0 0 1 465.12 543.24 Tm <6469736F72648072> Tj 0.00 Tc /F3 9.0 Tf 1 0 0 1 560.16 542.88 Tm <42> Tj 0.00 Tc /F3 7.0 Tf 1 0 0 1 450.36 527.76 Tm <537973626D696320> Tj /F3 6.5 Tf 1 0 0 1 479.52 528.12 Tm <6C7570757320> Tj 1 0 0 1 497.52 528.12 Tm <6572796C68656D61746F736973> Tj 0.00 Tc 1 0 0 1 450.00 512.28 Tm <546879726F696420> Tj 1 0 0 1 474.48 512.28 Tm <646C736F72646572> Tj 0.00 Tc /F3 11.0 Tf 1 0 0 1 560.16 511.56 Tm <6F> Tj 0.00 Tc /F3 6.5 Tf 1 0 0 1 450.00 496.80 Tm <5472656174726E656E7420> Tj 1 0 0 1 482.76 496.80 Tm <666F7220> Tj 1 0 0 1 492.84 496.80 Tm <6169636F686F6C> Tj /F3 6.0 Tf 1 0 0 1 450.36 488.52 Tm <6F7220> Tj /F3 6.5 Tf 1 0 0 1 457.92 488.52 Tm <6472756720> Tj 1 0 0 1 473.76 488.88 Tm <757380> Tj 0.00 Tc /F3 11.0 Tf 1 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El Yes o o A5thma o Arthritis Anxiety o Bleeding disorder n Blood disorde/dots o Carlce/malignancy o CerbrEl palsy tr ChickEn pox tl Chronic bronchitis/emphysema o Depression o Yes Olabtes mellifus tr Eaf ng disorder anorexianervosa, bulimia o Eyo disease tr Hay tever/sa3onalalleOieJ TT Heart disease tr Hepti6s High blood preslure tr High cholesterol tr Gallbladder disoder o lnfl ammatory bowel disease/Crohn's, ulceratrve colrtrs o Yes lmmune Compromised o Kidney Oisease o Migraine or recurenl headache n Muliiple sclercsis n Obeltty n Peptic ulcer n Pelvic infeclion o Phlebitidblood clot tr Polio o Prcsta6tis tr Rheumatic fever o Seizure disorder (epilepsy) o Yes Skin disordr B Sysbmic lupus erylhematosis Thyroid dlsorder o Treatrnent for aicoholor drug us o Tubrculosis o Treatrnent to preventbberculosas t-l Trcatnent br edivetuberqJiosis o Past pogrtve tubeaculin skjntest (Mantoux) o urinary disodedlnfedions t-l Oher (specify) Oo you have an illne6s or condition, not listed above, for which you are now being treated? O Yes O No lf yes, please specify: List date(s) and reason(s) for any hospitalizations and/or surgeries. Do you have any chronic medical prcblems? O Yes tr No lf yes, ptease have your phys6ian write a medical summary and attach to this form FAMILY MEOICAL HISTORY Check alldiseases that apply to your family: O Heart disease o Hypertension o Diabetes El Cancer O Blood clots O Stroke O Asthma O Other (pleas DISABILITY lf there are any other aspecls of your health that have caused problems for you or that might require special anangements at the University of Northernco|orado,p|easespecify:oVisionoEmotiona|/mentaloHearingoLearningoMobi|itytrother:- Please explain disability and special consideGtion needed: I authorize you to share informalion tegarding my disability with the appropriate University offices. 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rorrlinemeciical problems, r".o-"..od S#;;Health center. ln the event that the above-named student does not meet the immudzationrequirements to attend co1lege, I hereby give consent for immunizations to be artmini51s1gfl arneeded to meet the requirement- I understand that conkainilications and side effects of theirnmunization will be reviewed wifl my miror child ard he/she will be asked to sign a ftrtherconsent at the time immunizations are to be administered. I further understand thai costs or feesare my resporsibility.I understand that this authorization is valid until the time in which the minor identified abovereacnes tus/ner I6-' blrthdav. 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types ofacute illness and injury-However, ifat anytimeyou are referred offcampus to a specialist, Urgent Care orthe hospitalEmergenry Room, you are responsible for all those charges. Ifyou have any chronic illness it is alsohighly suggested that you obtain care from a local prrivider who would be available to you 24 hoursa day.All students are reminded that medical services are rendered and charged to the patient, nottheinsurance company. However, as a courtesy to our students who have the Student Health InsuranceProgram (SHIPJ, we will file those claims for you.I hereby authorize the Student Health Center to release to my insurance company any and all information they may qequire concerning my care. Assignment ofbenefits; I authorize the payment ofany benefit from the SHIP directly to the AV Student Health Center. INlTIAL IF YOU HAVE AV INSURANCE: Worker's Compensation and Auto Related Iniuries:The Student Health Center does not provide any care related to either ofthese conditions. 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I r:ndersta.d tl.at I em fina'cially responsibre for ar1 charges whether or not they arecovered by insurance. In tre event of defaurt, I agree to pay aJI costs of co[ection, andreasonable attorney's fees. I hereby authorize this healthcare provider to release allbJormation necessary to secure tlre payment of benetts.i further agree tl.at a photocopy of tris agreement shail be as valid as the ori6nar. I understa'd that i am ultimately responsible for arry irlcr:rred charges, co-paymentsor coinsurances for my treatment if my insurance does not cover such teafoaent. Iundersta'd trrat I ern responsible for co-paym.ents at the 'rne of sereice. I furtherundersta'd that failure to present my insurance card ai tt . ti-. of service may resultin being.registered as a self-pay urrd copy h". U..rr Jt"irr.a.I understarrd that I am responsibre for verifying my insurance benefits 2nd rimilqtiensfor my beatment as wel as veri-sing whether applicable treafuients will requireauthorization prior to services rendered. I 'ndersta'd tJrat quotation of benefits a'dauth.orizations is not a guarantee of payment from my insurance company. 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