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Forms
Records Release Form
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.
Travel Health Form
Should be printed, filled out, and brought to your appointment when receiving immunizations for travel.
Animal Lab Eligibility Clearance Forms
- Biosafety Level 2 Labs Clearance Form (labs with vertebrate animals with student exposure to allergens)
- Laboratory Animal Research Risk Assessment Questionnaire
- Laboratory or Field Animal Research Medical Clearance for Proposed Work
- Laboratory Bio-Medical Research Eligibility for Proposed Work
Matriculation Requirement Forms — Due July 21
Please do not call other departments on campus with Health Services related questions. The clinic is closed during summer but emails, voice mail, mail, and faxes are processed weekly.
All First Year Students
Instructions
- Register for the HaverHealth Portal. You will need your student ID number and Haverford email address to register. All required health forms are located in your portal.
- Submit your Health Forms by the deadline of July 21.
Required Health Forms
A late fee of $75 will be charged for failure to submit your fully completed health forms by July 21.
Submit forms (A-F) through the HaverHealth Portal.
- Immunization Verification Form
(Print, fill out, and submit via the Portal.) - Physical Examination
- Medical History, New Student Immunization History, and TB Screening
(Complete on-line in Portal.) - HIPAA Disclosure
(Print out and then submit your completed form via the Portal.) - Financial Responsibility
(Print out and then submit your completed form via the Portal.) - Health Insurance Card
(Submit copy of card via the Portal.) - Consent to Treat a Minor
Required if you are under the age of 18 at time of arrival. - Sports Medical Clearance Requirements
- Special Diet Needs
For students with a medically-related dietary need, such as food allergies and needs associated with Crohns, Celiac or diabetes. Complete in the HaverHealth Portal.
Returning Students
Complete the HIPAA form, financial responsibility form, immunization medical form, and submit a copy of both sides of your health insurance card via the HaverHealth Portal.
All Haverford students are required to have proof of health insurance that works within a ten mile radius of the campus.
International Students
All international students are required to purchase the College insurance plan.