Health Forms

Listed below are various Health & Counseling forms available for download; except where indicated, all forms are in PDF format. If you have any questions about any of these forms, please call Health Services at 585-245-5736 or Counseling Services at 585-245-5716.

Please note that if you require a copy of your immunization or medical records, you will need to proceed to our Immunization & Records Requests page for more information.  Students admitted prior to May 2004 and/or who require additional records should also see the Immunization & Records Requests page.

available forms

Authorization to Release Information Form

Release of Personal Medical/Health Information
This form grants the Health & Counseling department permission to share information with others, including health care providers, family members, Geneseo staff, and anyone else who you might designate.

Authorization to Release Information Form (PDF)

Health Services Verification of Student Absence Form

Verification of Student Absence
Health Services will provide documentation of visits of the student to professors, employers, or others provided that the student signs an Authorization to Release Information. Professors and other campus personnel requesting this information must ALSO submit the online form below.
Verification of Student Absence (online form)

Incoming Student Forms

Incoming Student Checklist
If you are an incoming student, please download this form to ensure that you have submitted all of the required information.
Incoming Student Checklist (PDF)

Physical Exam
If you are an incoming student, please download this form for your doctor's office to fill out.
Physical Exam 

Minor Student Forms

Consent for Medical Treatment of Minors
If you are under the age of 18 you will need to provide parental consent for medical treatment.
Consent for Treatment of a Minor 

Minor Students Seeking Counseling
If you are under the age of 18 and seeking counseling services, you will need either provide parental consent OR document that your parents have refused/are unable to provide parental consent.  The first form below is the Parental Consent Form; the second is the Minors' Consent Form.

Other Forms

Religious Exemption
If you hold a deep religious conviction that prohibits you from participating in the routine vaccination program, you need to fill out the form and submit it as a waiver for the New York State required immunizations.
Religious Exemption (PDF)

Counselor Change Request
If you have been seeing a therapist in Counseling Services and would like to work with someone new (same academic year), print the form below, complete the requested information, and drop it off at Counseling Services, Lauderdate 205.
Counselor Change Request (PDF)