Patient Resources - Downloadable Forms

UT Health Services Forms

For your convenience, download and print these forms prior to your visit. Please complete the forms and bring them to your appointment.

Note: UTHS forms and Vaccine Information Statements are in PDF format and can be downloaded and printed. If you do not have Adobe Acrobat Reader, you can download and install a copy from Adobe's Web site.

Medical Records Request New Employee/Visitor Health History Questionnaire
Patient History First Report of Injury
Occupational Health Program Enrollment Financial Disclosure Form-Travel
Pre-Travel Health Consultation

Vaccine Information Statements

Vaccine Information Statements (VIS) are information sheets produced by the Centers for Disease Control and Prevention (CDC) that explain to vaccine recipients, their parents or their legal representatives the benefits and risks of a vaccine. Please bring your shot records with you.

*Please note that insurance may not cover vaccines listed below.

Anthrax - Administer Only Polio
Hepatitis A (Series of 2) Rabies (Series of 3)
Hepatitis B (Series of 3) Shingles (Herpes Zoster)
Human Papillomavirus (HPV) (Series of 3) Tetanus/Diphtheria/A-cellular Pertussis (Tdap)
Influenza Tetanus Only
Japanese Encephalitis (Series of 2) Typhoid
Measles/Mumps/Rubella (MMR) Varicella (Chickenpox) (Series of 2)
Meningococcal Yellow Fever
Pneumococcal Polysaccharide