Clinic Schedule Request
Please PRIORITIZE clinic requests and reasons. We will do our best to accommodate; to do this effectively, please give enough information to allow proper understanding and triage.
Name (First Last) *
Your answer
Please give a reason or explanation for your clinic request *
Your answer
Service Month of Request *
Residents are allowed 3 clinic requests per academic year. Clinic requests are due 3 months in advance. Requests placed after this deadline may not be accommodated and it will be the responsibility of the resident to find coverage.
Provide your clinic cancellation request: month/day and AM/PM (i.e. 1/4 PM) *
Your answer
Please give AT LEAST two reschedule options (date AM/PM). If no dates provided, we will choose reschedule dates *
Your answer
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