Hand Sanitizer Request Form

Today's Date

Year/Month/Day

Name

E-Mail Address

Phone Number

Department or Organization

Position check all that apply

UofL faculty or staff

UofL student

Campus

Belknap
HSC
Other (specify in comments)

Location

Number of Hand Sanitizer Bottles Requested

Recipients Who is the hand sanitizer intended for?

Requested Pick-up Date

Year/Month/Day

Comments

Campus Health Services

Cardinal Station - Belknap

215 Central Ave., Suite 110
Louisville, KY 40208
P(502) 852-6479
F(502) 852-0660

HIPAA Notice of Privacy Practices
HIPAA Notice of Privacy Practices (en español)
Notice of Nondiscrimination

Health Care Outpatient Center - HSC

401 E. Chestnut., Suite 110
Louisville, KY 40202
P(502) 852-6446
F(502) 852-6649

Appointments - Belknap: (502) 852-6479
Appointments - HSC: (502) 852-6446
Insurance Advocate: (502)-852-6519
Immunization Coordinator: (502) 852-2708

Campus Health Services programs, services and resources are open to all eligible students, faculty (when applicable), and staff (when applicable), regardless of race, color, national origin, sex, disability, or age.