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Clark University
Office of
Health Services

Health Forms

Undergraduate Students (new incoming students only)

Students should make an appointment with their healthcare provider to complete the required health forms as soon as possible.

Please keep a copy of all of your forms for your records.

Upload health forms using Clark credentials

Clark University Health Services
950 Main St.
Worcester, Mass. 01610
Telephone: 1-508–793–7467
Fax: 1-508–751–5947

Make an appointment with your health care provider to have your physical completed. We will accept physicals within the past two years.

physical exam form

Please complete the top section of this form, sign and date it.   If all answers are no, no further testing is required.  If you answer YES to any of the questions,  you are required to have your healthcare provider complete the bottom section of the form, sign and date it.

TB screening form

This form needs to be completed, signed and dated by your healthcare provider.  You should try to complete as many of your required vaccines as you can prior to your arrival. There will be immunization clinics scheduled when you arrive at Clark University  for those immunizations you may not have completed or that are not available in your country.

Undergrad Immunization Form

 

Please complete the meningococcal form below only if you have not received the meningococcal vaccine which is required age 21 or younger.

meningococcal-info-waiver-updated-June-5-state-seal-2022

Complete only if your child is under 18 years old.

authorization to treat minor

Graduate Students (new incoming students only)

Students should make an appointment with their healthcare provider to complete the required health forms as soon as possible.

Please keep a copy of all of your forms for your records.

Upload health forms using Clark credentials

 

Clark University Health Services
950 Main St.
Worcester, Mass. 01610
Telephone: 1-508–793–7467
Fax: 1-508–751–5947

Please complete the top section of this form, sign and date it.   If all answers are no, no further testing is required.  If you answer YES to any of the questions,  you are required to have your healthcare provider complete the bottom section of the form, sign and date it.

TB screening form

 

This form needs to be completed, signed and dated by your healthcare provider.  You should try to complete as many of your required vaccines as you can prior to your arrival. There will be immunization clinics scheduled when you arrive at Clark University  for those immunizations you may not have completed or that are not available in your country.

Grad Immunization Form

Complete only if age 21 years of age or under and did not receive meningococcal vaccine ACWY.

meningococcal-info-waiver-updated-June-5-state-seal-2022

Accelerated Degree Program Students

Undergraduates students who enter a master’s degree program after earning their B.A. as part of Clark’s Accelerated Degree Program must submit a new TB Risk Questionnaire and a meningococcal waiver. Immunization records on file will be reviewed by the Health Services and students will be notified by email if additional immunizations are needed.

Upload health forms using Clark credentials

Please complete the top section of this form, sign and date it.   If all answers are no, no further testing is required.  If you answer YES to any of the questions,  you are required to have your healthcare provider complete the bottom section of the form, sign and date it.

TB screening form

This form must be completed if you are 21 years of age or younger and did not receive a meningitis vaccine at 16 years of age or older.

meningococcal-info-waiver-updated-June-5-state-seal-2022

Contact Information

Health Services

Office Location
Office Hours

  • Health Services is open Monday through Friday, 9 a.m. to 5 p.m.
    Health Services is closed when the University is closed.

  • Directions:
    Health Services can be reached either from Park Avenue or Birch Street. To get to Birch, take Maywood Street (heading toward Park Avenue) and then turn right onto Birch Street. Follow the signs to the Health Services building.