Health Forms

Printable Versions

 

Health Form
Instructions
CMMC Pharmacy / Bates College Delivery Request Form Print, Complete, and Sign.

If you are interested in having your prescriptions delivered to Bates College where you can pick them up at Post and Print, fill out the following form and simply send it to us by one of two methods:

      • Attach it Electronically to our Online Form:
              – If you don’t have it electronically you can use your phone/tablet to take a snapshot of it and attach that to our online Form.
      • Mail to:
        Bates Health Services
        31 Campus Ave.
        Lewiston, ME 04240
Authorization for Release of Student Health Information Print, Complete, and Sign.

This form is to request the release of your health information from Bates College to you, your parents, and/or legal guardian(s). This forms also serves as a release to authorize the providers and/or other third parties listed on the form to verbally communicate, send and/or receive the medical information listed in Part III on the form to the Bates College Health Services. Send it to us by one of two methods:

      • Attach it Electronically to our Online Form:
              – If you don’t have it electronically you can use your phone/tablet to take a snapshot of it and attach that to our online Form.
      • Mail to:
        Bates Health Services
        31 Campus Ave.
        Lewiston, ME 04240
CMMC Pharmacy Patient Demographic Form Print, Complete, and Sign.

This information is requested by CMMC Pharmacy so we can provide appropriate pharmacy services to you. Fill out the following form and simply send it to us by one of two methods:

      • Attach it Electronically to our Online Form:
              – If you don’t have it electronically you can use your phone/tablet to take a snapshot of it and attach that to our online Form.
      • Mail to:
        Bates Health Services
        31 Campus Ave.
        Lewiston, ME 04240
Credit Card Authorization Form Print, Complete, and Sign.

CMMC Pharmacy accepts MasterCard and Visa (including debit cards and/or health plan benefit “benny” cards which have the MasterCard or Visa designation)(“Credit Card”) for the payment of fees incurred at CMMC Pharmacy. Fill out the following form and simply send it to us by one of two methods:

      • Attach it Electronically to our Online Form:
              – If you don’t have it electronically you can use your phone/tablet to take a snapshot of it and attach that to our online Form.
      • Mail to:
        Bates Health Services
        31 Campus Ave.
        Lewiston, ME 04240
Immunization Exemption Form Print, Complete, and Sign.

**Where an immunization exemption has been previously granted, the written request for exemption must be sent to Bates Health Services to become part of the school health record. In the event that a communicable disease, including but not limited to measles, mumps, rubella, or pertussis, is identified on campus, students who are not immune from that disease shall be excluded from school for one incubation period following the latest case of the disease. Students who are excluded from school may have to withdraw from the college for the remainder of the semester or longer, depending on the timing and length of incubation period. If a previously non-immune student then receives MMR immunizations following the identification of a disease on campus, this student must wait one incubation period following completed MMR immunization before returning to school. Please note, incubation periods vary based on disease type and “completed MMR immunization” is defined as 2 doses of MMR separated by 28 days after the first birthday. Fill out the accompanying form and send it to us by one of two methods:

      • Attach it Electronically to our Online Form:
              – If you don’t have it electronically you can use your phone/tablet to take a snapshot of it and attach that to our online Form.
      • Mail to:
        Bates Health Services
        31 Campus Ave.
        Lewiston, ME 04240

Have Questions? Need Help?

Please feel free to contact us either by email, healthservices@bates.edu, or by calling 207-786-6199.