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Haverford College
Health Services

Services: Forms

Contact Info

Mailing address:
Haverford College Health Services
370 Lancaster Avenue
Haverford, PA 19041-1392
(Only add if being mailed from outside the U.S.)

Fax: 610-896-1090
Phone: 610-896-1089
Email: Please email both Dotty Gardler, Administrative Assistant, and Catherine Sharbaugh, Director, at and

Required Forms

The Health Clinic is closed between the end of spring semester and the start of fall semester. However, we will review voicemail and email and follow through as needed on a weekly basis. Please do not call other departments on campus with Health Services related issues.

June - All First Year Students

Authorize release of sickle cell trait newborn records. This form should be filled out by you and given to your health care provider. Also, please confirm your status via the Moodle site.

July 21 – All First Year Students

  1. Physical Examination (PE) Form PDF, including record of current immunizations. Please send the PE Form, completed by a health care provider (not a parent), to Health Services via fax or mail, or scan and email the form to both the administrative assistant and director.
  2. Confidential Health Record (available to complete around 6/4/13 when you get your student ID .

A late fee of $75 will be charged for failure to submit fully completed health forms by July 21.

August 1 – First Year Students and Returning Students

All Haverford students are required to have proof of health insurance. Students must waive or enroll in health insurance (available to complete around 6/4/13 when you get your student ID#). Waive, enroll or to see a full list of accepted insurance plans.
*Be sure to look for an email confirmation after registering.

A late fee of $35 will be charged for failure to complete registration by August 1.

Students are responsible for all incurred medical expenses. Effective August 2011, Health Services accepts some medical insurance for clinical services. Students can submit bills directly to their insurance plan. Students can also continue to submit all charges to their student account for reimbursement from their insurance plans or pay by check or cash.

Students should bring their insurance card, or copy of their card, with them during their first visits to the Health Center for us to scan into our system. Should a student drop or change coverage at any point during the school year, he or she must notify Health Services immediately of the change (up-date TBA).

August 1 - International Students

Note that, from time to time, overseas health insurance has proven not to work in favor of students. Since the United States does not offer public health services for non-citizens, hospital costs can be alarming. Because Haverford requires its students to have adequate private health insurance, we highly suggest you purchase the College.

Students must meet the Health Services requirement before arriving on campus for the International Students Orientation (ISO).

Due before or upon arrival on campus – First Year Students

If you will be younger than 18 years of age at time of arrival, your parent/guardian must complete the Consent to Treat a Minor Form PDF and send it to Health Services.

August 29 – First Year Students (Opening Day)

If any health form or insurance registrations are not met, you will need to report directly to Health Services upon arrival.

Other Forms You May Need

Records Release Form PDF
If you wish to have a copy of your medical information shared with someone else, you will need to authorize Health Services to release your record. Visit Services: Confidentiality for more information >

Travel Health Form PDF
Should be printed, filled out, and brought to your appointment when receiving immunizations for travel. Visit Services: Travel Health for more information >

Bi-Co Dietitian Special Diet Needs Form
Please let the Bi-College Dietitian know about any food allergies or special dietary needs that you have. Fill out the form, save it to your computer, and either email ( or to ensure confidentiality, print and mail the form to Nicole Patience (address listed at the bottom of the form).