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Health Forms

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  5. Health Forms

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View and download forms you'll need before making a visit to the Nebraska Medicine – UNO Health Center.

Medical History

  • Medical History (Female)
  • Medical History (Male)

Power of Attorney

  • Power of Attorney Form Instructions
  • Power of Attorney form for patients who are 18
  • Power of Attorney form for patients who are 18 (En Espanol)

Notice of Privacy Practice (HIPAA)

Influenza Vaccination Form

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  • Notice of Privacy Practices
  • Rights and Responsibilities of Patients

Nebraska Medicine UNO Health Center

  • Health Matters
  • Telehealth: Care Anywhere
  • Cost and Insurance
  • One Chart | Patient
  • Student Health Insurance Information
  • New Student Health Requirement
  • Immunizations
  • Health Forms
  • Appointment Information
  • Our Services

How To Submit

Download forms and bring them to the Nebraska Medicine – UNO Health Center in 102 H&K or fax them to 402.554.2387.

Additional Resources

  • Student Safety
  • Counseling and Psychological Services (CAPS)
  • Injury Prevention & Care
  • Alcohol and Drug Support

Contact Us

Nebraska Medicine UNO Health Center

102 H&K 
6001 Dodge Street
Omaha, NE 68182

Hours
Monday-Friday
8 A.M. to 4:30 P.M.

402.554.2374 

Please dial the full 10-digit number whether on or off campus.

After-Hours Care

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