Hendrix Clinic and Counseling Center

Attention Newly Admitted Students

The following immunizations form and health history must be printed, completed, and returned to the health center before you can register for classes. You may submit the immunization information online or print out a copy to be sent to Hendrix Clinic and Counseling Center. Please keep a copy for your records.

(You will need Acrobat Reader in order to view and print these forms.)

Required prior to registering for classes.

• Online Immunization Form

• Immunization Records For Students Attending MSUM

• More information on Immunizations

Other forms:

• Authorization and Request for Release of Medical Information

• Authorization and Consent for Treatment of Minors

If you request a copy of your health information to be given directly to you, there may be a charge based on the number of pages copied. There may also be a charge for records sent to insurance companies or legal offices.

Fax number:

(218) 477-5867

Mailing address:

Hendrix Clinic and Counseling Center
1104 7th Ave. S
Moorhead, MN 56563

Release of Health Information Form

Request to Obtain Health Information from Another Facility Form