University Health Center Forms

Allergy Extraction Letter and Administration Form – Required for the administration of allergy serum injections at the UHC. Sample of completed form.

Fine Appeal Form – For students who want to appeal a fine placed by the UHC on their account.

First Aid Kit Loan Request – The UHC has first aid kits to loan JMU student groups for travel.  The designated JMU Faculty/Staff advisor for the group may request kits with this form.

Grievance Policy and Form – For students who would like to formally make a complaint or grievance regarding their dissatisfaction with the UHC.

Health Information Receipt – For students requesting a copy of their entire health record. Requires a $10 fee and must accompany the Health Information Release Form.

Health Information Release – For FORMER students requesting any portion of their health record. Current students can do this from MyJMUChart (formerly MyJMUHealth).

Hepatitis B and Meningitis Immunization Waiver – Needed for any student who would like to waive these vaccines.

Immunization Form – State required, must be signed by a health care provider and uploaded as a .pdf to MyJMUChart. Non-compliance will result in $50 fine and academic hold.

Translated Immunization Forms – Available in Arabic, Chinese, French, German, Italian, Japanese, Korean, Russian, Spanish, Thai and Vietnamese.

Medication/Order Authorization – For students who are prescribed an injectable medication that needs to be administered in our Nurse Clinic. An example of an injectable medication is Vitamin B-12.

Student Prescription Delivery Form – For students who are prescribed injectable or IV medications only that need to be delivered to the Health Center. Once the electronic form is complete, the student will be notified once delivered. All medications must be picked up the same day as delivery. The UHC is not responsible for any medications left overnight. If medications are to be administered at the Health Center, the Medication/Order Authorization form above must also be submitted.

Religious Exemption Form – For students exempting immunizations due to religious reasons.