Necessary Forms

Menactra, the vaccine for protecting against some strains of meningitis is offered in the clinic.   Because of the cost of the vaccine it is necessary that yout pay for the vaccine prior to our placing the order.  The clinic will notify you by phone when the vaccine arives and will assist you in making an appointment to receive it.

Meningicoccal Vaccine Order Form>>>(MSWord)

CNU requires all first time, full time students living in residence halls to receive the meningicoccal vaccine.  In acordance with the code of VA, if you choose not to received the vaccine, you must still receive information about meningitis, the vaccine and sign a waiver.  This information is also available in the clinic.

Meningitis Vaccine Waiver>>>>(MS Word)

CNU Immunization Form>>> (MS Word)

First appointment in Health & Wellness Services?

Save time.....get the necessary health history form to fill out before your visit!
Personal Health History and Consent to Treat  >>>>>>***   If you will not be 18 years old, you must have a parent or guardian sign this form.

  (MS Word, be sure to print all pages!)

• If you have been seen in the clinic and have already filled out the Personal Health History form &:
• Have changed your local address/telephone number or
• Have had any changes to your medical health/status,
• Please let us know by filling out and bringing in a Returning Patient Form>>>>>>>>>  (MS Word)

Confidentiality & Medical Information and Records
  WIthout written consent no medical information may be released to or from Health & Wellness Services.

You may request information to be released by using one of two forms.   

Confidentialtiy and Medical Information  Release  >>>>>>>>>>>