A parent or legal guardian must give consent in order for U-M students who are minors (under age 18) to receive health care services at University Health Service (UHS).
A parent or legal guardian should complete this form. (You may use free Adobe Acrobat Reader to read the form.)
After competion, please mail the form to:
University Health Service
207 Fletcher Street
Ann Arbor MI 48109-1050
Or fax to 734-936-3063
This form is for use at University Health Service only. It does not pertain at Michigan Medicine hospitals or clinics.
Please do not upload this consent form when submitting immunization records.