Health Form

Personal Information

First Name

Last Name

Student ID Number

Date of Birth

Gender

Primary Care Provider Information

Name of Primary Care Provider

Address of Primary Care Provider

Date of Last Physical Exam

Emergency Contact Information

Primary Emergency Contact First & Last Name

Relationship to you

Primary Contact Phone Number

Primary Emergency Contact Physical Address

Secondary Emergency Contact Name

Secondary Emergency Contact Phone Number

Third Emergency Contact Name

Third Emergency Contact Phone Number

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

Allergies & Reactions (Please list any medication, food, or environmental alergies)

Please list any current prescription medications & reason for the medication

Have you been diagnosed with any infectious disease? If so, please describe.

Do you currently have any medical conditions that MACU should know about to keep you safe while you are a student? If so, please describe.(ex. History of seizures, cancer diagnosis, etc...)

Are you presently physically disabled or restricted? If so, please explain.

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.

YesNo

Immunizations

Shot/Vaccination/Immunization Record Upload (Please select a pdf or picture of your record)

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.
It is most common to obtain your immunization record from your primary care doctor or your state health department.

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