DELAWARE STATE UNIVERITY
STUDENT HEALTH SERVICES
PATIENT CONSENT
CONSENT FOR EXAMS – TEST – TREATMENT – SERVICES
I, _______________________ agree to be examined, have appropriate tests, receive
treatments or referrals, or receive any other services by an authorized person of the
Student Health Center for those problems which may be discovered during an
examination.
I agree to accept responsibility for any additional and/or follow-up care that may not be
available from the Student Health Center. In case of an emergency, I have been told
to go to the local hospital emergency room.
I agree to release and hold harmless Delaware State University, the Student Health
Center and its agents and/or employees from any liability for physical injuries suffered as
a result of any exams, test, treatments, and/or services received. In addition, I consent
to the Health Center taking samples, cultures, or lab tests that are deemed necessary.
In case of situations that I need to be reached for results of these tests, I can be reached
by:
___ Cellular phone
Can we leave a voicemail message – yes/no
___ Room/Home phone
Can we leave a voicemail message - yes/no
___ E-mail
E-mail address________________________
I understand that if I reside in campus housing and do not have a campus post
office box, a letter will be left under my door.
I understand that information is confidential unless specifically released by me the
patient, with the exception of disease information mandated by state/federal law. I have
had the opportunity to receive and review the Health Insurance Portability and
Accountability Act Notice of Privacy Practices.
This consent shall apply to these medical office actions for medical care for a period of
one year from the date of signature.
IT IS A POLICY OF THIS OFFICE THAT YOU GIVE 24 HR NOTICE TO CANCEL A FAMILY PLANNING
APPOINTMENT. FAILURE TO COMPLY WITH THIS POLICY COULD RESULT IN YOU NO LONGER
BEING ELIGIBLE TO RECEIVE FAMILY PLANNING SERVICES. I UNDERSTAND THAT IF I MISS ( 3)
FAMILY PLANNING APPOINTMENTS WITHIN THE CURRENT SCHOOL YEAR, I WILL NO LONGER BE
ELIGIBLE TO RECEIVE FAMILY PLANNING SERVICES AT THE STUDENT HEALTH CENTER FOR
THE REMAINING OF THE SCHOOL YEAR.
IF WE ARE UNABLE TO REACH BY THE METHOD(S) YOU HAVE CHOSEN, WE WILL SEND YOU A
LETTER - _________Initials
______________________________
Student Signature
________________
Date
_________________________
Office Agent Signature
_______________
Date
Updated 01/10 GM
DELAWARE STATE UNIVERITY
STUDENT HEALTH SERVICES
Updated 01/10 GM