Health Services Request Form

This form will allow you to request an appointment with Health Services. You will receive an email from the MSOE nurse practitioner based on your response.

If you are off campus and in immediate danger, please call 911.
If you are on campus and experiencing a medical crisis, please call MSOE Public Safety at 414-277-7159.

MSOE Health Services does not write notes to excuse students from missing class. Students should be in good communication with their professors if they feel they are too ill to attend class in person.

* = required field

Full Legal Name *

First

Last

Preferred 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 (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 are 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 same message via email. Once your request has been reviewed, you will receive a follow up email from the MSOE nurse practitioner by the next business day. If you do not get a pop up & email confirmation, it means your request was not received. *

I will get a pop up window & confirmation email if my request is submitted.

I will need to resubmit the form if no pop up message & email is received.

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Milwaukee School of Engineering

Health Services Request Form

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