Student Health Requirements TO BE COMPLETED BY STUDENT Please complete this form with your healthcare provider and submit your documents to: ORU Student Health Services EMR Dorm, First Floor, NS 102 ● Office: (918) 495-6341 7777 South Lewis Avenue ● Fax:...
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Student Health Requirements TO BE COMPLETED BY STUDENT Please complete this form with your healthcare provider and submit your documents to: ORU Student Health Services EMR Dorm, First Floor, NS 102 ● Office: (918) 495-6341 7777 South Lewis Avenue ● Fax: (918) 495-6274 Tulsa, OK 74171 ● Email: studenthealth@oru.edu GENERAL INFORMATION Student ID Number: Z Home Telephone No.: Date of Birth: ❑ Male ❑ Female Cell Telephone No.: Plan to Enter University: / Last Name First Name Middle Initial Month Year Entering as: ❑ Fr ❑ So ❑ Jr ❑ Sr ❑ Grad Home Address Student Status: ❑ Full-Time ❑ Part-Time City State Zip Code Country I plan to live: ❑ On Campus ❑ Off Campus [For Returning Students]: Dates of Previous Enrollment: to EMERGENCY CONTACT: Please provide the name, relation, and phone numbers of a family member or other person to be contacted on your behalf in an emergency: Name Relationship Home or Cell Phone Work or Cell Phone * ATTENTION INTERNATIONAL STUDENTS: The above-listed emergency c
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