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 practioner 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

Date of Birth *

Student ID Number *

Phone Number *

###

####

Biological Gender *

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 in Health Services for upper respiratory symptoms (fever, cough, nasal congestion, sore throat, shortness of breath, etc.) please enter the date of your at-home covid test and the result. If you have taken an at-home Covid test, please do so before requesting an appointment.

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. *

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Milwaukee School of Engineering

Health Services Request Form

Health Services Request Form

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