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.

* = required field

Full Legal Name *

First

Last

Preferred First Name

Date of Birth *

Student ID Number *

Email Address *

Phone Number *

###

####

Sex at Birth: *

Gender You Identify Best With *

Do you live on campus? *

Yes

Student Status *

1st Year

2nd Year

3rd Year

4th Year

5th Year +

If you are requesting an appointment due to upper respiratory symptoms: a recent negative covid test result is required before an appointment will be scheduled for students with any of the following symptoms: fever, chills, nasal congestion, sore throat, cough, shortness of breath, body aches, loss of taste or smell. If you have not taken a covid test, take one before completing this form. Please list the date you took the test and the result.

Please give a brief description of why you are requesting to be seen. *

Please list the date that your symptoms/concerns started. *

Please list weekdays (Monday-Friday) and blocks of time (between 8am-4pm) that you are available to meet with someone. 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. *

I understand I will get a response to this request by the end of the next business day. *

I understand the timing

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Milwaukee School of Engineering

Health Services Request Form

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