Health Form
Personal Information
First Name
Last Name
Student ID Number
Date of Birth
Gender
Please select...
Female
Male
Primary Care Provider Information
Name of Primary Care Provider
Address of Primary Care Provider
Date of Last Physical Exam
Emergency Contact Information
Emergency Contact First & Last Name
Relationship
Secondary Emergency Contact
Phone Number
Third Emergency Contact
Phone Number
Primary Emergency Contact Physical Address
Insurance Card Information
Insurance Company
Insurance Policy Number
Please Upload a Copy of Your Insurance Card
Insurance Attestation
I understand that the University requires me to carry personal health insurance and that any medical expenses incurred while a student at Mid-America Christian University will be my sole responsibility.
I understand
Health Information Continued
Allergy & Reaction
Medication & Reason for Medication
Have you been diagnosed with any infectious disease? If so, please describe.
Are you presently physically disabled or restricted? If so, please explain.
Shot Record Upload
Emergency Attestation
If there is any instance in which emergency contact cannot be reached, and where delay would be dangerous to my medical health, I hereby authorize the administrators of Mid-America Christian University to grant permission for emergency operation or medical treatment of an extraordinary nature, for which the attending physician considers necessary.
Yes
No
Immunizations
Oklahoma Statute, Title 70 3244 requires documentation of the student's immunization to be provided to Mid-America Christian University. The following shots are required: Measles, Mumps, Rubella (MMR), Hepatitis B, and Meningitis. If you have opted not to receive these immunizations, please sign the Immunization Waiver form and submit it to the Office of Student Life.
The Office of Student Life
Mid-America Christian University
3500 SW 119th St
Oklahoma City, OK 73170
Email:
studentlife@macu.edu
Text: 405.458.0922
Phone: 405.692.3242
Fax:405.692.3165
Contact Information