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Forms & Request Records

Student Consent for Treatment, Telehealth, and Privacy Practices
Please print, read, sign, and upload this document into your Health Portal before your first appointment, or if you are 18 years of age or older, you can sign electronically
HEREThis is a new requirement for all students beginning June 2019. This document was updated September 18, 2020.

Employee Consent for Treatment, Telehealth, and Privacy Practices
Please print, read, sign, and upload this document into your Health Portal before your first appointment, or if you are 18 years of age or older, you can sign electronically
HEREThis is a new requirement for all employees beginning June 2019. This document was updated September 18, 2020.

Please print and take these forms to your allergist to complete and fax to 615.460.6131.

Permission to Administer Allergy Medication

Allergen Immunotherapy Order Form

Release of Information from Belmont

Release of Information to Belmont