Student Health Service Forms

Overview

All students must complete and return all forms prior to arrival on campus. Deadline for return is July 15 for students beginning study in the fall and January 1 for students beginning in January. All information disclosed will be kept confidential and will be shared only with appropriate University personnel on a need-to-know basis.

Forms can be emailed to vdelani@lesley.edu; faxed to 617.349.8225 or mailed to Lesley Student Health Service, 29 Everett Street, Cambridge, Ma 02138.

For All Undergraduate Students

• Student Health Form
• Mental Health History
• Physical Examination Form
• Certificate of Immunizations for Undergraduates
• Meningitis Information Sheet and Waiver Form

Optional Health Service Contract for Off-Campus Students

Student Health Service is available for Non-Resident Full-Time Undergraduate Commuters.

Contract Information

To sign up for this optional service you must complete and return the contract to Student Health Service before the third week of classes for each semester you wish to enroll. The $400.00 fee will be charged to your student account and is non-refundable.

• Optional Student Health Service Contract

NOTE: This service is NOT health insurance. Only non-resident full-time undergraduate students are eligible for this service.

Health Service Disclosure Forms

A student can request their medical records be sent from or to SHS after completing the following consent forms for records release.  Record requests are processed in the order received and generally require five to seven business days to complete. If you have additional questions regarding records, please contact vdelani@lesley.edu.

• Complete and sign the Release of Medical Information Form; authorization for release of medical information. Note: Please use this form to request that your records are sent from an outside provider or facility to Lesley Student Health Service.
• Complete and sign the Immunization Disclosure Form for release of immunization records.
• Disclosure forms must be complete with correct phone/fax numbers, contact information and complete signature.
• Signed and completed disclosure forms can be emailed to vdelani@lesley.edu; faxed to 617.349.8225 or mailed to Lesley Student Health Service, 29 Everett Street, Cambridge, Ma 02138.