Ensure that your immunizations are up to date. You must submit this form annually if you are a student in a health-related professions program.
For the best experience use a non-mobile device.
- This form requires the signature or stamp of your health care provider.
- Your health care provider must provide the requested information on this form. Students are not allowed to fill it out themselves.
-This form must be completed in English.
University at Buffalo
Michael Hall, 3435 Main Street, South Campus
Buffalo, NY 14214
Phone: (716) 829-3316; Fax: (716) 829-2564
UB's Health Services is unable to provide information about the NY State Department of Health’s COVID vaccination clinics being held at Harriman Hall on UB’s South Campus. For information about these clinics, including eligibility and to make an appointment, please call the NYS Health Department’s COVID vaccine hotline phone number: 1-833-697-4829 (1-833-NYS-4-VAX) or refer to their website.