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 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 +

The date that your symptoms/concerns started: *

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

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.

If applicable, 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. *

I understand I will get a response to this request no later than by the end of the next business day. *

I understand the above statement regarding timing of a response.

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Milwaukee School of Engineering

Health Services Request Form

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