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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
Phone: (419) 448-2041
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 20, 2012:

Download a pdf packet of all health forms

  1. 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. Complete all of the tuberculosis screeening questions at the bottom of the Medical History Questionnaire Form-page. If you answer "yes" to any of the tubercoulosis 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
    3. 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 2001 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
    4. 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.
    5. 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.
    6. 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.
  2. A Copy of both sides of your Health & Pharmacy Insurance Cards.
  3. New Patient Consent to the Use & Disclosure of Health Information form.

    4. All Athletes

    Please complete the above requirements 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 Card
    4. Acceptance of Risk/Medical Authorization Form
    5. Medical Questionnaire Form-Pages 1 &2
    6. New Patient Consent to the Use & Disclosure of Health Information

    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.