Saint Xavier University Health Center

Health Center

New/Existing Patient Paperwork

New Patient Registration Form (PDF)
Please complete information on both sides of this form as describing the scheduled patient.

State of Illinois – Certificate of Child Health Examination (PDF)
Parent should complete the child's name, address, date of birth, phone number and health history on the second side of this form. Please be sure to bring a copy of the child's immunization records so our staff can complete the vaccine portion appropriately.

State of Illinois – Illinois High School Association Pre-participation Examination (Sports Physical Form) (PDF)
Parents should complete Side 1 of this form (demographic information and past medical history).

Patient Records Release (PDF)
Please complete this form and submit to the Health Center in order to have records released for our office. There is no charge for this service.