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

Full Legal Name *

First

Last

Preferred First Name

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:

If you are requesting an appointment due to upper respiratory symptoms: if you have recently taken an at-home covid test due to your current symptoms, please list the date you took the test and the result.

Please list any home remedies you have tried to resolve your symptoms and whether they have helped or not:

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 8am-4pm) that you are available. Please list multiple blocks of time over several days. Note: Health Services is not available after 4pm on weekdays and are closed on weekends and holidays. *

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Milwaukee School of Engineering

Health Services Request

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