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Forms

There are some forms that students can complete in advance of an appointment, which may save time!

 

Other forms may need to be completed by your health care provider (either at the Health Service or in the community):

New Patient Package

Students who have never been to the Health Service should print, complete and bring these forms to their first appointment at the clinic. The forms include a New Patient Assessment Health Assessment form, a Web Access Acknowledgement form and a Next of Kin Information form.

Click here to view and download the New Patient Package forms (pdf)

 

Consent Form for International Patients International Students with UHIP (University Health Insurance Plan) need to complete a consent form and submit it when they check-in for their first appointment at the clinic.

Click here to view and download UHIP Authorization Form

Health Assessment Questionnaire


Please complete and print this form in advance of your appointment for a Complete Physical Exam and bring it with you to your appointment.
 

Click here to view the Health Assessment Questionnaire Form (pdf)

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 Pre-Travel Information Form


Please bring the completed Pre-Travel Information Form to the Health Service when you come for your Travel Medicine appointment.

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Student Medical Certificate


Health Service Policy: Health Service physicians are available to assess University of Toronto students presenting with a medical concern, and provide treatment whenever possible. However, only students with a SERIOUS illness will be granted a certificate for deferral of an exam or other academic work.

Mild colds, non-acute diarrhoea and/or vomiting, headaches, menstrual cramps, insomnia or other non-acute problems may benefit from medical advice and/or treatment, but may not warrant a certificate. Non-medical issues, such as a death in the family, should be addressed through your college (if A&S) or faculty registrar. 

Please note: A Health Service physician can only provide a certificate if you were seen in the department while you were ill or injured, or for a past illness that is recorded on your medical record and affected your academic work. If you are ill and unable to attend an appointment with a health-care provider, but also unable to attend an exam, please notify your professor and/or registrar.

While our policy may seem strict, it is in place to ensure fairness. The physicians and nurses at the University of Toronto Health Service are available and willing to help all students with their health care needs and to stay healthy throughout the academic year, including at exam time.

If you are feeling unwell and unsure if your illness meets criteria for a certificate, please consult a doctor. Students are also welcome to consult their own doctors in the community.

Click here to download a copy of the form to be completed by physicians outside of the University of Toronto.

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 Authorization For Release of Medical Information
 

This form will permit a Health Service physician to release necessary medical information to a specific recipient. You may print out the form, and have your doctor fill it out as required.

In the case of a third-party request, patients are responsible for the cost of the physician chart review, duplication and transfer of your health records. The cost will be $25.00 for chart review and photocopy.

Please note:  There is a $5.00 charge for replacement of documentation that has previously been completed by your health-care provider for a third party.
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For Flu-Related Absence: Since students are being encouraged to stay at home if they’re feeling unwell, the university has developed guidelines around the temporary suspension of the need for a doctor’s note or medical certificate in relation to flu-related absences. In order to receive academic accommodation, students will need to record all flu-related absences through a new tool on the Student Web Service of ROSI @ http://www.rosi.utoronto.ca.

For a full explanation of the university’s guidelines on flu-related absences, visit http://www.preparedness.utoronto.ca/pandemic/Information_for_Students.htm (see the section entitled “H1N1 flu-related absences”).

Problems and Troubleshooting


In order to view and print these forms, you must use a .PDF file viewer.  We recommend that you install one of these free viewers:


If you do not have an Acrobat .PDF file viewer, or are experiencing problems attempting to view any of these forms, then please click on the appropriate link below to view a .GIF version of the medical certificate (please note, the Acrobat .PDF version has better quality and prints out better, so we recommend that you try downloading those first before trying these).

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