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Self Identification of Special Needs

If you have a medical condition that you would like us to be aware of, we encourage you to complete this form.  The information on this form will be emailed to a designated staff member of Campus Health Services. Upon receipt of this form, a Campus Health Services medical provider will review the information and determine if more information will be needed from you. This information that you submit will be recorded into your health record at Campus Health Services and will be held in confidence. Campus Health Services respects and preserves the privacy and confidentiality of patient and personnel information.  Information whether written, spoken, recorded electronically, or printed will receive the same level of protection.  If you would like more information regarding confidentiality and privacy at Campus Health Services, please see the links on the right.

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