Connors State College

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Health and Wellness Referral Form

Name (First, Last) *

Student ID Number *

Email *

Date of Birth *

YYYY

Home Address *

Phone number *

Alternate Phone Number

Are you currently covered by insurance? *

Yes

Insurance Company Name

Policy Number

Group Number

Are you currently enrolled as a full-time student? *

Yes

Reason for visit. (Please state the reason why you are requesting a visit to the Health and Wellness). *

I understand that CSC has an agreement with the Health and Wellness Company and will pay $30.00 for current full-time students for health services per visit. The student will be responsible for any additional expenses incurred, such as any medications, supplies, or additional services. Any subsequent visits will be at the patient's expense, unless a new referral has originated from Connors State staff. *

I agree

Required

Submit

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