Request a Distance Consultation
Effective March 16th, Grossmont Health & Wellness is closed until further notice but offering advice nurse appointments via phone as well as referrals to community resources via email during regular business hours (Monday-Thursday: 9am - 5pm; Friday: 9am - 1pm).

IF YOU ARE EXPERIENCING A MEDICAL OR MENTAL HEALTH EMERGENCY, PLEASE CALL 911.
Sign in to Google to save your progress. Learn more
Date: *
MM
/
DD
/
YYYY
Name: *
Email:
Phone: *
Student/Employee ID: *
Date of Birth: *
MM
/
DD
/
YYYY
Briefly explain your reason for this request (medical or mental health) *
If you are requesting a phone appointment, please list your availability:
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms