Authorization for Release of Medical Information from FAU
Print a blank form and then complete the form by hand.

Deliver the form to Student Health Services via one of the following methods:

• Fax a signed copy to (561) 297-0494.
• Mail a signed copy to:
  Florida Atlantic University
  Student Health Services
  777 Glades Road
  Boca Raton, Fl 33431
• Bring a signed copy to the Student Health Services office.

Authorization for Release of Information to FAU
To have your medical records sent to FAU, print and complete the form and provide it to the provider in possession of your records. Please allow sufficient time prior to your appointment for Student Health to receive your records.

• Dental Clinic
• Student Health Services
• Pharmacy

Prior to receiving an immunization from Florida Atlantic University's Student Health Clinic, please complete the appropriate consent form for the immunization that you are receiving. Be sure to read the corresponding What You Need To Know Vaccination Information Sheet before signing the consent form.

If you are under the age of 18, your parent or legal guardian must also sign the consent form. Additionally, if you have never been seen before in our clinic, you will also need to fill out the Medical History Form and sign the Release to Treat section on the second page.

Vaccine Consent Form
What You Need To Know
CDC Publication date 7/18/2007

Vaccine Consent Form
What You Need To Know
CDC Publication date 2/2/2007

Vaccine Consent Form
Inactivated Influenza Vaccine: What You Need To Know 2007-2008
CDC Publication date 7/16/2007

Vaccines Consent Form
Measles Mumps & Rubella Vaccines: What You Need To Know
CDC Publication date 1/15/2003

Vaccine Consent Form Meningococcal Vaccine: What You Need To Know
CDC Publication date 1/28/2008

Vaccine Consent Form
Pneumococcal Polysaccharide Vaccine: What You Need To Know
CDC Publication date 04/16/2009

Vaccine Consent Form
Tetanus, Diptheria, Pertussis (Tdap) Vaccine: What You Need To Know
CDC Publication date 7/12/2006

See our Frequently Asked Immunization Questions for more information about Immunization requirements.
Immunization Form
Immunization FAQs

Note: If you have never been seen before in our clinic, you will need to print and fill out the Medical History Form and sign the Release to Treat section on the second page. Bring the completed form to your appointment.
Medical Health History Form