St. Andrews Health and Wellness Form
  1. This is confidential information and will not be released without your authorized permission.
  2. First Name(*)
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  3. Middle Name(*)
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  4. Last Name(*)
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  5. Gender(*)
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  6. Social Security Number(*)
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  7. Date of Birth(*)
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  8. Street Address(*)
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  9. Cell Phone(*)
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  10. Email(*)
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  11. Year Entering(*)
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  12. Semester Entering(*)
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  13. Home Physician
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  14. Physician Phone
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  15. Physician Address
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  16. Are you currently insured?(*)
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  17. Please upload a copy of insurance card.
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  18. Name of insurance carrier
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  19. Policy Number
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  20. Group Name
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  21. Mother/Guardian Name
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  22. Mother/Guardian Phone
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  23. Father/Guardian Name
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  24. Father/Guardian Phone
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  25. Emergency Contact(*)
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  26. Emergency Contact Phone(*)
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  27. Please list all allergies here.
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  28. Please describe any and all medication you are currently taking.
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  29. Please attach certificate of immunizations.
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    This must include DTP, complete series of measles, mumps, and rubella immunizations, and completed meningococcal vaccine information.
  30. Please check all that apply.
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  31. Signature (*)
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    I authorize the release of information to listed individuals and understand this authorization may include the need for St. Andrews University to share medical information to authorized individuals including mental and physical health issues.
  32. Release to:(*)
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  33. Name of person releasing to
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  34. Students over 18 years of age are responsible for signing their own form. Students under the age of 18 must have a parent sign the health form.
  35. All statements in this form are true to the best of my knowledge and I have no limitation or restriction in this record. I agree to notfiy St. Andrews University of any change that occurs in my physical or mental health. I give St. Andrews University permission to contact my parents, doctor, and/or pharmacy should the need arise. In the event that I transfer to another school, I give St. Andrews University permission to release my records to the appropriate authority.
  36. Signature (*)
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  37. Date(*)
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  38. Please enter the characters in the image(*)
    Please enter the characters in the image
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