New Student Medical Form

Email Address

First Name

Last Name

USM Student ID

Birthdate

Mailing Address

Country

Street

City

Region

Postal Code

Permanent Address

Country

Street

City

Region

Postal Code

Emergency Contact Info

Emergency Contact Relationship

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Mobile Phone

Insurance

Primary Insurance Company Name

Primary Insurance Policy Holder's Name

Primary Insurance Policy Number

Primary Insurance Group Number

Upload a copy of the front of your insurance card below (accepted file types: .doc, .docx, .pdf, .png, .jpeg, .jpg) :

Upload a copy of the back of your insurance card below (accepted file types: .doc, .docx, .pdf, .png, .jpeg, .jpg) :

Medical History

Please describe any allergies:

Please describe any current medical conditions:

Please describe any past medical conditions:

Please list any current medications:

By typing my name below and clicking the submit button, I agree and understand that the electronic submission of this form constitutes my official signature as stipulated by the University of Saint Mary and the state of Kansas.

Student Signature (type name)

Today's Date