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Boynton Health

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  1. Resources
  2. Forms & Documents

Forms & Documents

Medical Records and Billing Forms

  • Immunization Requirements Form
  • AHS Immunization Form
  • Veterinary Immunization Form
  • Health Information Release Form
  • Billing Information Release Form
  • Bloodborne Pathogen Exposure Procedure 

Patient Forms

Dental

  • Dental Communication Consent
  • Dental Medical History
  • Dental Patient Responsibility Statement

Medical

  • PrEP Agreement Form
  • Cologuard Order Requisition Form

Mental Health

  • Controlled Substance Agreement Form
  • Academic Medical/Disability Supplement Form
  • Student Services Fee Assessment Request Form
  • ISSS Health Information Release Form
  • DRC Health Information Release Form

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About Boynton Health

Boynton Health serves students, faculty and staff of the University of Minnesota Twin Cities, providing comprehensive health care with a public health approach to campus well-being.

Patient Rights and Responsibilities
Compliance and Quality Assurance
Accreditation
Employee Intranet
Media

Appointments

For appointments:
612-625-3222

Nurse line open 24/7:
612-625-7900

Crisis line open 24/7:
612-301-4673 

Location

Get Directions:
410 Church St S.E.
Minneapolis, MN

Clinic Hours:
Mon. 8am-4:30pm
Tues. 8am-4:30pm
Wed. 8am-4:30pm
Thurs. 8:30am-4:30pm
Fri. 8am-4:30pm
Closed Sat. & Sun.

Additional Locations

Parking

Connect

Email
[email protected]

Fax
612-677-3211

For Students, Faculty, and Staff

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  • MyU
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  • About
    • Mission, Vision, and Values
    • Staff Directory
    • Locations & Hours
    • Student Health Advisory Committee
    • Donations
  • Medical Care
    • Make an Appointment
    • Get Care Now
    • Primary Care
    • Pharmacy
    • Dental
    • Eye Clinic & Optical Shop
    • Physical Therapy
    • Travel Clinic
    • STI Testing
    • Biometric Health Screening
    • Gynecology
    • Nutrition
    • Gender Care
  • Mental Health & Counseling
    • Mental Health
    • Group Therapy & Workshops
    • Mental Health Training (for employees)
    • Mental Health Internship and Practicum Programs
    • Mental Health Tool (Help Compass)
  • On Campus
    • Pet Away Worry & Stress (PAWS)
    • Nutritious U Food Pantry
    • College Student Health Survey
    • Naloxone Locations
    • Sexual Health
  • Vaccinations
    • Vaccine Requirements
    • Get Vaccinated
  • Billing & Insurance
  • Resources
    • New Student Guide
    • For International Students
    • For Faculty & Staff
    • Forms & Documents
    • Marketing & Communications