Student Medical Form - Carolina

!!
Student Medical Form
Instructions for Completing Medical Form
DEADLINE'FOR'COMPLETED'MEDICAL'FORMS'AUGUST'1'
'$100'Late'Fee'
1
ͻϯDTP!(!Diphtheria,!Tetanus,!and!Pertussis)!Tdap!Booster!must!have!within
!!the!last!10!years.
ͻϮDDZ;DĞĂƐůĞƐ͕DƵŵpƐ͕ZƵďĞůůa).
!Physical!Exam!within!lasƚϭϮŵŽnths.
DĞĚŝcal!History!(completed!ďy!student).
Ϯ͘
remainder'of'the'form.'Make'sure'that'he/she:
ͻůů Ěates!must!include!month,!day!and!year.
ϯ͘Students'who'plan'to'play'intercollegiate'sports or attend Presbyterian School of Nursing!must!
send!this!completed!form!to!the!Health and Wellness Center in addition to any athletic or PSON
requirements.Our requirements are different and BOTH are necessary.
4.!
Services,'(704)'337S2220.
*All'records'must'be
legible'and'in'English.
please!return!to:
1900!Selwyn!ve.
͘DEdKZzƌĞƋƵŝƌĞŵĞŶƚƐĨŽƌĂůůŶĞǁƐƚƵĚĞŶƚƐ;&ƌĞƐŚŵĂŶ͕dƌĂŶƐĨĞƌƐĂŶĚ/ŶƚĞƌŶĂƟŽŶĂůͿ
dƵďĞƌĐƵůŝŶ^ŬŝŶdĞƐƚ;WWͿǁŝƚŚŝŶƚŚĞůĂƐƚLJĞĂƌ͘
Please'enclose'a'front'and'back'copy'of'your'insurance'card'when'you'submit'your'medical'form
Copy of Insurance Card OR
Taking the Queens United Healthcare Insurance Policy
Charlotte, NC 28274
Fax to:704-337-2333
OR E-mail to: medicalrecords@queens.edu
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