As you begin your college experience, please note that several health requirements must be completed before you move onto campus and/or begin classes. 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
Phone: (419) 448-2041
Fax: (419) 448-2372
All students, including residential students and commuters, must return the following information via fax or mail to the Heidelberg University Health Center in order to begin classes and/or be issued a room key card:
Download the health forms:
A completed Medical History Questionnaire Form is required for all students including the following immunization requirements.
- 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.
- Complete all of the Tuberculosis Screening questions in the Immunization Data Section of Page 2 of the Medical History Questionnaire form. If you answer “yes” to any of the tuberculosis screening questions, a Tuberculin Skin Test (Mantoux) or chest x-ray is required. You may 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
- A Tetanus/Diphtheria (TDaP or TD Booster) is required. Date of your most recent vaccination must be within the past 10 years to fulfill this requirement (the year 2004 or later). Please indicate if you would like Heidelberg personnel to administer the DTaP booster when you arrive in August (page 2). Cost: $40.00
- Varicella (Chicken Pox). No vaccine is necessary if you have had the disease. Vaccination is required if you have not had the disease, have not previously recieved the vaccination (2 doses) or have a negative varicella antibody titer. This vaccine is not available at the Heidelberg Health Center and must be administered at a medical facility of your choice.
- Hepatitis B vaccination series (3 injections-total cost $90.00 or $30.00/injection for students 19 yrs. and younger) are REQUIRED. The cost for the series of 3 doses if you are over 19 yrs. of age is $180.00 or $60.00/dose. Please indicate if you would like Heidelberg personnel to administer these vaccinations on page 2 of the Medical Questionnaire form.
- Meningitis Vaccine ( Menactra/Menomune) is STRONGLY RECOMMENDED. Please indicate if you would like Heidelberg personnel to administer the menactra vaccine. Cost: $110.00. Even though the Health Center only charges the students for vaccinations and testing at our cost, we advise you check with your local health department or medical provider to find the most economical source.
- A Copy of both sides of your Health & Pharmacy Insurance Cards.
- New Patient Consent to the Use & Disclosure of Health Information form.
Please complete the above requirements. Additional forms will be completed at the time of your on-campus athletic physical.
Please note: Please note that your athletic physical examination will be completed by Heidelberg University physicians when you arrive on campus for a nominal fee. The dates and times for the physical examination will be in conjunction with the date you will be moving onto campus in August and will be communicated to you prior to your arrival.
Please mail or fax the above required forms before you arrive on campus. Also note that any forms submitted to the athletic training staff or coaches will not insure immediate participation. The forms are reviewed by the Health Center personnel before final authorization to participate is permitted. There is a 2-week processing period for all health forms.
Please complete the above requirements along with the Sickle Cell Trait Reporting Form.
If you have questions, please call 419.448.2041 or email firstname.lastname@example.org.