Get Immunization And Medical Record Request Form - Southeastern ... - Selu

Completing the Immunization and Medical Record Request Form efficiently will help you obtain your medical records with ease. This guide provides step-by-step instructions to assist you in filling out the form accurately.

Follow the steps to successfully complete your request:

1. Press the ‘Get Form’ button to acquire the form and open it for editing.
2. Fill in your personal details. Provide your full name, phone number, and university identification number (W#).
3. Enter your date of birth and indicate your first semester at Southeastern (for example, Spring ‘06). This information helps in retrieving your records.
4. Indicate whether you have been a patient at the Health Center by selecting ‘Yes’ or ‘No’. This field is crucial, so please make your choice carefully.
5. Select the type of medical information you are requesting by checking the appropriate boxes for Immunization Record, Lab Reports, Consultation Notes, and others. You can also specify other types of records in the space provided.
6. Indicate your preferred method of receiving your records by circling 'faxed', 'mailed', or 'in hand'. Provide the necessary contact details accordingly, including the fax number or mailing address.
7. Sign and date the form to validate your request. Ensure your signature is clear for processing.
8. After completing all sections, save your changes. You can download, print, or share the form as needed.

Complete your Immunization and Medical Record Request Form online for a swift and hassle-free experience.