Health record requests
Student Health Services maintains medical records on all students for up to seven years after graduation. If you would like a copy of your immunization records, pap smears, other labs or complete medical record, you can go to the student health portal, https://connc.studenthealthportal.com, sign in, and see if you are able to access the information you need there. If you cannot access the information you need please fill out the Health Records Request Form and submit the appropriate payment due ($5 for immunization/ pap smear records; $20 for complete medical record). We advise all graduating seniors to obtain copies of their immunizations before leaving the College.
Student health forms
Please be sure to review the Student Health Insurance Plan and, if you have comparable private insurance, to waive out at www.gallagherstudent.com/conncoll. You must also email a copy of your private insurance card, front and back, to Student Health Services at SHS@conncoll.edu.
Forms for new and transfer students entering Fall 2017:
- Connecticut College Health History Form (filled out via the Student Health Services' Web Portal, http://connc.studenthealthportal.com/).
The due date for completion of this form is July 15, 2017.
- Medical Clearance and Proof of Immunizations Form
Please print and take this form to your physician for completion. Once complete, you must log into the patient portal (http://connc.studenthealthportal.com) and enter your immunization dates into the Immunization History Form. Then you may scan and upload the form via our Student Health Services' Web Portal, http://connc.studenthealthportal.com/ under "Document Upload," or scan and email it to SHS@conncoll.edu, or fax it to us at (860) 439-5430. The due date for completion of this form is July 15, 2017. If your physical is not scheduled until after July 15, 2017, please be sure to complete all of the other information and submit the form before your arrival on campus.
Forms for current/returning students:
- Health Records Request Form
- Acknowledgment of Financial Responsibility Form
- Study Abroad Health Screening Form
- Consent to Treat
- State of Connecticut Religious Exemption Form
- Medical Leave Return Letter
- Student Health Services Medical Leave Exchange of Information Form
- AD/HD Exchange of Information Form (pdf)
- SHS Exchange of Information Form
- Exchange of Information Form/Medications Refills
- Online Waiver of Student Health Insurance - Consult the Insurance info page
- Club Sports Informed Consent Form (pdf)
- TRIPs Health Screening Form (pdf, short form)
- Pre-Travel Health Questionnaire (for use after acceptance to program)
- Temporary Medical Need Accommodation
- Aetna Claim Form (pdf)
Form required of varsity athletes
- The Athletic Health Screening Form is required of all varsity athletes. It must be returned to the Athletic Trainer, NOT to Student Health. All students who planning to participate in varsity sports who did not play here last year must submit this form by July 14, 2017. NCAA rules require all physicals be dated within six months of the first sports participation with the team. Connecticut College does not accept physical exams performed by a family member. Make sure the form is completed in its entirety on both pages; keep a copy, and mail to: Head Athletic Trainer, Box 5245, Connecticut College, 270 Mohegan Avenue, New London, CT 06320 or fax to (860) 439-5033.
Counseling Services requests background information
- After making an initial appointment with Student Counseling Services, we request that all students fill out the needed background information forms. To access these forms, please go the following URL: https://buttonbush.conncoll.edu/titanium_web/launch.htm. Once the page opens, click on the tab for "Intake." Again we ask that you please complete these forms prior to your initial appointment.
Confidentiality release for third parties
- Due to confidentiality laws and ethical practice standards, NO information is shared with anyone outside the SCS offices. If you require information to be shared with a third party, we will need you to complete the release of information form:
- Authorization to Disclose/Obtain Protected Health Information (PDF). If you have questions regarding confidentiality, please speak with your counselor at the time of your initial appointment or ask to speak with the director of student counseling services.