Please complete the following to obtain all or part of your medical records. Form may be faxed or emailed to

Title Description

The Privacy Practices document is to be read (not to be submitted) and confirmation of receipt must be signed at the bottom of the Health History form. If you have any questions regarding the privacy practices, please contact Student Affairs. Thank you.

Privacy Practices Page 1 (read only)


Privacy Practices Page 2 (read only)