1. 1. 1. 1. Health History Section:
            1. This section be can filled out completely online. In most cases, the information needed to complete this form can be obtained with your parent/guardian.
            2. To view a completed example, click here.

            Consent to Medical Treatment Section:

            1. This section be can filled out completely online. Only a signature is required to complete this form.
            2. To view a completed example, click here.

      TB Screening Section:

      1. 1. If you answer “No” to the first five questions at the top of the form you can electronically sign and submit it. That’s all you need to do. To view a completed example, click here.
         2. However, if you answer “yes” to any of the first five questions you will need to have your healthcare provider fill out the TB Testing Form.
         3. You can print out the TB Testing Form, have it completed by your healthcare provider and then return it to Bates Health Services by:
            • • • Attach it Electronically to the TB Testing Form:
                  • • • • – Click

                        here to attach and upload your TB Testing Form.

                  • • – If you don’t have it electronically you can use your phone/tablet to take a snapshot of it and attach it to the TB Testing Form.

2. Vaccine Form:

This form must include your vaccination record from your healthcare provider. This could be this form printed and completed by your healthcare provider or you could attach a copy of your official vaccination record from your healthcare provider’s office. Once completed, you can send it to us by one of two methods:

• Attach it Electronically to the Online Vaccine Form:
  • • – Start a new Vaccine Form online and attach your completed Vaccine Form signed by your healthcare provider or a copy of your official vaccination record from your healthcare provider’s office.
  • • – If you don’t have it electronically you can use your phone to take a snapshot of it and attach that to the online Vaccine Form.

• First, take a deep breath.
• Second, complete your forms as quickly as possible.
• If you need help don’t hesitate to contact Health Services either by email, healthservices@bates.edu, or by calling 207-786-6199.

• Your Personal Contact Information
• Place of Birth
• Parent/Guardian Contact Information
• Personal Health History, including any chronic medical conditions, allergies, medications, and surgeries
• Primary Care Physician

• Yes, when you click on “Finish” to complete the form you will have an option to “Show” the document. You can then print it.
• You will also receive a copy of the form in your email so you can view it and print it after completing the form.

• You are required to have a Parent/Guardian sign your health forms.
  • • There will be two roles to complete:
      • For the “Student” Role, the Student’s name and Bates Email address should be entered.
      • For the “Parent/Guardian” Role, the name of the Parent/Guardian and their associated email address should be entered.***The form will be sent to the email address used for the Parent/Guardian***

  The student can first fill in all the information in the form, sign it and it will be automatically sent to the Parent/Guardian’s email address.

  • The Parent/Guardian can sign the form and it will be sent to Bates Health Services.

Yes, you can print the form using one of the following approaches:

• Print the form, which you can view here, TB Testing Form, have your healthcare provider fill out the appropriate sections and send it to Health Services.
• Check out this Step by Step Video Guide

• You can print out the form, have it completed by your healthcare provider and return it to Bates Health Services by:
  • • • Attach it Electronically to the Online TB Testing Form:
        • • • • – Click

              here to upload your TB Testing Form.

        • • – If you don’t have it electronically you can use your phone/tablet to take a snapshot of it and attach that to the online TB Testing Form.

• • • Attach it Electronically to the Online Vaccine Form:
      • • – Start a new Electronic Vaccine Form online by using the link on the main site and attach your records to the form. Within the electronic form you will see an icon that you can select to upload your documents.
      • • – If you don’t have your records electronically you can use your phone to take a snapshot of it and attach that to the online Vaccine Form.