Use this form to officially change your name through SIU School of Medicine.

Instructions

OFFICIAL DOCUMENTATION AND VALID IDENTIFICATION MUST BE PRESENTED WITH A COMPLETED REQUEST FORM. 

Acceptable forms of ID include state-issued picture ID and one of the following:

  • Marriage certificate
  • Divorce decree
  • Court order
  • Birth certificate

You can fill out the form below and submit it to the SIU School of Medicine Registrar

Form Download