Dear New Amherst Students and Families,
Welcome to Amherst College. As an Amherst student, you will be eligible to use the Health Center throughout the academic year. Please feel free to contact us or make an appointment to discuss any health concerns while you are at Amherst. We need to receive certain information from you in order to provide appropriate health care when necessary, to promote the goals of the College, and to comply with state law and regulations. Please refer to the check list below in order to submit all of the necessary completed information. Forms may be submitted by mail, fax, email attachment, or in person. However, it is imperative that we receive them no later than January 18, 2013. If your health file is not complete, you will not be able to register for courses when you arrive on campus!
1. Physical Exam Form —completed by a licensed medical provider (physician, PA, or nurse practitioner) who is not a family member. The examination must have been performed within twelve months of your arrival at Amherst.
3.New Student Immunization Form—must be completed by your medical provider. If immunization status is unknown or incomplete, obtain an antibody titer for measles, mumps, rubella, Hepatitis B, and varicella or arrange for re-immunization (as outlined on the attached Immunization Form) when you receive the required physical examination from your medical provider.
4.Learning and Accommodation Form—read and complete.
5.Email Consent Form —read and complete.
7. INSURANCE INFORMATION—please send us a copy of both sides of your insurance card (not necessary if you have purchased the Amherst College Student Injury and Sickness Insurance Plan).
Thank you for your assistance in meeting these college requirements. If you have any questions regarding these forms, please contact the Keefe Health Center’s Office at 413-542-2267 or email@example.com.
Warren Morgan, M.D. Michele Wojtowicz
Medical Director, Keefe Health Center Office Manager,Keefe Health Center