Health Services Request

Complete this form to request an appointment with the nurse practitioner. Don't need an appointment but have a health-related question? Please email health@msoe.edu instead of completing this form.

* = required field

The nurse practitioner will not be available for appointments on Friday, October 17th. If you need to be seen urgently, please be seen of- campus at a local urgent care. *

I understand the above information.

Full Legal Name *

First

Last

Date of Birth *

Sex at Birth: *

Gender You Identify Best With *

Student ID Number *

Email Address *

Phone Number *

###

####

Do you live on campus? *

Yes

Student Status *

1st Year

2nd Year

3rd Year

4th Year

5th Year +

Brief description of why you are requesting to be seen: *

The date that your symptoms/concerns started (put N/A if it does not pertain): *

Please list any home remedies you have tried to resolve your symptoms and whether they have helped or not (put N/A if does not pertain or if you have not tried anything): *

Do you have any additional information you would like to share about your request? If so, please share here:

Please list weekdays (Monday-Friday) and blocks of time (between 9am-4pm) that you are available for an appointment. Please list multiple blocks of time over several days. Note: Health Services is not available after 4pm on weekdays and is closed on weekends and holidays. *

Once this form is submitted, you will see a pop up window, stating your request has been received. You will also receive this via email. Once your request has been reviewed, you will receive a follow up email from the MSOE nurse practitioner. *

I understand the above information.

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Milwaukee School of Engineering

Health Services Request

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