This form is intended for 2nd and 3rd year Physical Therapy students. Please review the information in its entirety. If you have any questions, please contact the East Campus medical staff at 513-584-4457 during business hours. 8:00am - 4:30pm Monday - Friday.
This form must be filled out by your primary care provider and signed by both the provider and the student.
The completed form can be faxed to 513-584-2222
Mailed to: University Health Services 1st Floor Holmes P.O. Box 670460 Cincinnati, Ohio 45267-0460
You may also bring the form to the UHS Holmes clinic during the business hours listed above.
University Health Services East Campus Clinic University of Cincinnati Academic Health Center Holmes Building room 1007 200 Albert Sabin Way Cincinnati, OH 45267-0460 Phone: 513-584-4457; Fax 513-584-2222
Campus Clinics:
