Forms

Flu Vaccine Clinic Forms

Watkins Health Service hosts flu vaccine clinics each fall. More information coming soon.

Immunization History Form

The University’s Immunization History Form (PDF)* is required to be filled out by a physician or nurse and provided to Watkins Health Services. 

  • U.S. Students:  Seventy-two (72) hours after enrolling at orientation, you will be able to log into the Watkins Health Services patient portal. Click on the "Medical Clearances" tab and select "Immunization Record" to upload your form. 
     
  • International Students: Download and prepare this form before your arrival at KU. It must be completed in English and signed by your doctor. Three weeks prior to your health check-in appointment, log into Watkins Health Services patient portal. Click on the "Medical Clearances" tab and select "Immunization Record" to upload your form.

*In lieu of this form, Watkins Health Services can also accept an official copy of immunizations from a personal physician’s office, school, military, state record or childhood immunization booklet.

Health History Form

Students with allergies, complex medical conditions or chronic health issues should consider completing their Health History form online prior to a visit at Watkins Health Services. This will enable our clinicians to have advanced notice of significant issues that may be impacting your health. 

  • U.S. Students:  Seventy-two (72) hours after enrolling at orientation, you will be able to log into to Watkins Health Services patient portal. Click on the "Medical Clearances" tab and select "Health History Form" to get started.
  • International Students: You will receive instructions from International Support Services regarding access to Watkins Health Services patient portal

Authorization for Use/Disclosure of Information Form

The WHS Authorization for Use/Disclosure of Information (PDF) is used when patients want to request their past healthcare information be disclosed to entities outside of Watkins Health Services. This form is not acceptable for use by students to pre-authorize disclosure of any healthcare information that will be collected or created in the future. We do not allow students to sign these forms in advance of receiving care because they do not yet have a full understanding of what their information may contain, thus, this would not be a true "informed consent." If questions arise about the use of this form, please contact our Registration & Records Department at 785-864-9506 or 785-864-9494.

Pharmacy Prescription Transfer Form

To transfer a prescription to Watkins Pharmacy, complete the Prescription Transfer Form (PDF) and bring it or fax it to our pharmacy.

Spouse/Domestic Partner Guarantor Form

Student spouses and/or domestic partners are eligible for the same services as currently enrolled students. The following form must be completed by the enrolled student.  For more information refer to our Eligibility for Services.

Spouse - Domestic Partner Guarantor Form (PDF)

Insurance Form

We will submit claims to any insurance company although we are only in-network with certain carriers. We recommend that you have a copy of your insurance card with you at all times.  If you do not have a card for your insurance, we recommend this completed Insurance Information Form (PDF) be with you at all times.  Upon your first visit to Watkins, we will ask for this information.

Advance Directives Forms

Two legal documents that protect your right to refuse medical treatment you do not want, or to request treatment you, do want, in the event you lose the ability to make decisions yourself. (These documents will be legally binding only if the person completing them is a competent adult.) These documents may be requested by emailing whs-notifications@ku.edu.

The first is the Durable Power of Attorney for Health Care. Your Durable Power of Attorney for Health Care lets you name someone to make decisions about your medical care—including decisions about life support—if you can no longer speak for yourself. The Durable Power of Attorney for Health Care is especially useful because it appoints someone to speak for you any time you are unable to make your own medical decisions, not only at the end of life.

The second document is called the Health Care Directive, or DNR (“Do Not Resuscitate”). Your Health Care Directive, or DNR lets you state your wishes about medical care in the event that you become terminally ill and can no longer make your own medical decisions. The Declaration becomes effective if your death would occur even with the use of life-sustaining medical care. (Your doctor and one other physician must personally examine you and certify in writing that you are in a terminal condition.)

Frequently asked questions about completing your Durable Power of Attorney

Whom should I appoint as my “agent?”

Your “agent” is the person you appoint to make decisions about your medical care if you become unable to make those decisions yourself. Your agent can be a family member or a close friend whom you trust to make serious decisions. The person you name as your agent should clearly understand your wishes and be willing to accept the responsibility of making medical decisions for you. (An agent may also be called an “attorney-in-fact” or “proxy.”)

The person you appoint as your agent cannot be any of the following individuals, unless he or she is a member of a religious community to which you both are bound by vows, or is related to you by blood, marriage or adoption:

  • Your doctor or other treating health care provider, or
  • An employee of your treating health care provider, or
  • An employee of any hospital, psychiatric hospital or psychiatric treatment facility, hospice, nursing home or similar institution.
You can appoint a second person as your alternate agent. The alternate will step in if the first person you name as agent is unable, unwilling or unavailable to act for you.

How do I make my Durable Power of Attorney for Health Care legal?

The law requires that you have your Durable Power of Attorney for Health Care witnessed. You can do this in either of two ways:

  1. Have your signature witnessed by a notary public, or
  2. Sign your document in the presence of two witnesses, at least 18 years of age. These witnesses cannot be:
    • The person you appointed as your health care agent,
    • Entitled to any portion of your estate,
    • Directly financially responsible for your health care, or
    • Related to you by blood, marriage or adoption.

Should I add personal instructions to my Durable Power of Attorney for Health Care?

Organizations advise you not to add instructions to this document. One of the strongest reasons for naming an agent is to have someone who can respond flexibly as your medical situation changes and deal with situations that you did not foresee. If you add instructions to this document, you might unintentionally restrict your agent’s power to act in your best interest. Instead, we urge you to talk with your agent about your future medical care and describe what you consider to be an acceptable “quality of life.”

What if I change my mind?

You may revoke your Durable Power of Attorney for Health Care at any time by executing a new Durable Power of Attorney for Health Care, or by executing a written revocation that must be witnessed in the same way as your Durable Power of Attorney for Health Care.

Frequently asked questions about completing your Health Care Directives

Watkins Health Services requires that you talk with one of our physicians before completing this form.

How do I make my Health Care Directives legal?

The law requires that you have your Health Care Directives witnessed. You can do this in either of two ways:

  1. Have your signature witnessed by a notary public, or
  2. Sign your document, or direct another to sign it, in the presence of two witnesses, at least 18 years of age, who must also sign the document to show that they personally know you and believe you to be of sound mind, and that they do not fall into any of the categories of people who cannot be witnesses.

These witnesses cannot be:

  • The person who signed the Health Care Directives on your behalf.
  • Related to you by blood or marriage.
  • Entitled to any portion of your estate, or
  • Directly financially responsible for your medical care.

Can I add personal instructions to my Health Care Directives?

Yes, you can add personal instructions to your document. (See examples on form.)

If you have appointed a health care agent and you want to add personal instructions to your Health Care Directives, it is a good idea to write a statement such as “Any questions about how to interpret or when to apply my Health Care Directives are to be decided by my agent.”

It is important to learn about the kinds of life-sustaining treatment you might receive. Consult your doctor about Advance Directives and End-of-Life Decisions.

What if I change my mind?

You may revoke your Health Care Directives at any time by:

  1. Obliterating, burning, tearing, or otherwise destroying or effacing the Health Care Directives.
  2. Signing and dating a written revocation, or directing another to do so on your behalf, or
  3. Orally expressing your intent to revoke the Health Care Directives in the presence of a witness who is at least 18 years of age and who must sign and date a written confirmation of your oral revocation. An oral revocation becomes effective once your doctor receives written confirmation of it, at which time he or she must make it part of your medical record.

After you have completed your documents

  1. Your Durable Power of Attorney for Health Care and Health Care Directives (DNR) are important legal documents. Keep the original signed documents in a secure but accessible place. Do not put the original documents in a safe deposit box or any other security box that would keep others from having access to them.
  2. Give photocopies of the signed originals to your agent and alternate agent, doctor(s), family, close friends, clergy and anyone else who might become involved in your health care. If you enter a nursing home or hospital, have photocopies of your documents placed in your medical records.
  3. Be sure to talk to your agent and alternate, doctor(s), clergy, and family and friends about your wishes concerning medical treatment. Discuss your wishes with them often, particularly if your medical condition changes.
  4. If you want to make changes to your documents after they have been signed and witnessed, you must complete new documents.
  5. Remember, you can always revoke one or both documents.
  6. Be aware that your documents will not be effective in the event of a medical emergency. Ambulance personnel are required to provide cardiopulmonary resuscitation (CPR) unless they are given a separate order that states otherwise. These orders, commonly called “pre-hospital do-not-resuscitate orders,” are designed for people whose poor health gives them little chance of benefiting from CPR. These orders must be signed by your physician and instruct ambulance personnel not to attempt CPR if your heart or breathing should stop. Currently not all states have laws authorizing non-hospital do-not-resuscitate orders.

State of Kansas Living Will (Advance Directive)


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After Hours Care

24-hour Nurse Helpline:
785-864-9583

For immediate emergency help after normal business hours, call 911. LMH Health is located at 325 Maine Street.