New Students Health Requirements and Forms

As you begin your college experience, please note that several health requirements must be met before or at the time of your arrival in August. Available below are all medical forms required for students and student athletes. If you are a student athlete, please make sure to complete both sets of forms. ALL forms should be sent to:  

Heidelberg University Health Center
310 E. Market Street
Tiffin, Ohio 44883
or
Fax: (419) 448-2372

All Students

ALL STUDENTS, including athletes and commuters, must return the following information via fax or mail to the Heidelberg University Health Center by July 15, 2009:
 

Download a pdf packet of all health forms

 
A. A completed Medical History Questionnaire Form( 2 pages) required for ALL students  including the following immunization requirements.

  1. Childhood immunization record dates are required including MMR (2 dates), Polio (3-4 dates) and DPT (3-4 dates).  Hint:Your high school should have a copy of your childhood immunization record on file.
  2. An updated Tuberculin Skin Test (Mantoux) is required and must be administered after February 2009 or request that the Health Center provide the testing shortly after your arrival at Heidelberg University.  Indicate on the medical form (page 2) that you would like Heidelberg personnel to administer the test. Cost: $5.00
  3. A Tetanus/Diphtheria Booster is required. Date of most recent vaccination must be within the past 10 years to fulfill this requirement (the year 2000 or later) or indicate if you would like Heidelberg personnel to administer the booster when you arrive in August (page 2). Cost: $20.00
  4. Varicella (Chicken Pox). No vaccine is necessary if you have had the disease. Vaccination is required if you  have not had chicken pox and have not previously received the vaccination.
  5. Meningitis (Menactra) (Cost: $85.00) & the Hepatitis B vaccination series (3 injections-total cost $75.00 or $25.00/injection) are HIGHLY RECOMMENDED but NOT required at this time.  Please indicate if you would like Heidelberg personnel to administer these vaccinations on page 2.

B. A Copy of both sides of your Medical & Pharmacy Insurance Cards.

C.  New Patient Consent to the Use & Disclosure of Health Information form.

 

 

 All Athletes

Please complete the above forms and the following additional forms including:

  1. Pre-participation Physical Evaluation History Form
  2. Pre-participation Physical Evaluation Physical Exam Form signed by an MD or DO (No chiropractic exam will be accepted.)
  3. Emergency Information Form
  4. Acceptance of Risk/Medical Authorization Form

 Please note: Incomplete forms or missing forms will restrict you from participating in any practices or games. If you are planning to play a collegiate sport and you choose to wait and bring your forms with you when you arrive on the Heidelberg campus in August, this will delay your opportunity to begin practicing with your team. Also note that any forms submitted to the Athletic Training Staff or coaches will not insure immediate participation. The forms are reviewed by Health Center and athletic training personnel before final authorization to participate is permitted.