Request Forms

REQUEST FORMS

The following forms can be downloaded and completed prior to your scheduled appointment. Please follow additional form requirements that may be listed next to each link.


Medical Records Release Request
To request a Medical Records Release, click on the link below, complete the form and return it to the Health Service.

•     Authorization for Release of Medical Records Request Form (PDF)


Please complete and return this form to the Health Service via one of the following methods listed below:

U.S. MAIL: University of Pittsburgh
Student Health Service
Nordenberg Hall – Wellness Center
119 University Place
Pittsburgh, PA. 15260
FAX: 412-383-1820
Delivery in Person: Do NOT Email.  We cannot accept any Medical Release forms via EMAIL !!

Safe Sex Materials Request
To request Safe Sex Materials for your Student Organization’s Program, click on the link below, complete the form and return it to the Health Service return address posted on the form.

•     Safe Sex Materials Request Form

•     Outreach Initiative Ad