Student Medical Appointment Request Form
Medical Health Services at The Health Center of Walla Walla
Reach us by email at:
help@thehealthcenterww.org
Or by phone at: (509) 525-0704
* Required
Email address
*
Your email
Name of Person Completing this Request
*
Your answer
Relationship to student:
*
Self
Parent/Guardian
School Health Provider
Other:
Last Name of Student/Patient
*
Your answer
First Name of Student/Patient
*
Your answer
Student/Patient's Date of Birth
*
MM
/
DD
/
YYYY
Student/Patient's Age
*
Your answer
Appointment Request Type
*
In person at HUB (only for Sports physicals and Vaccine administration)
Telehealth (Limited to visits that do not require a lab test or physical assessment)
Reason for appointment (Chief Complaint). If requesting vaccine list which one(s).
*
Your answer
Email for parent/guardian if younger than 18 years old. Email of student/patient if 18 years old or older. If younger than 18 years old, the parent/guardian will be required to complete a Permission Form. The Permission Form will be sent to the email entered below via "Adobe" and MUST be completed prior to scheduling the appointment.
*
Your answer
Name of School Student/Patient attends
*
Your answer
What is the best phone number to reach the parent/guardian if younger than 18 years old or if student/patient is 18 years old or older. (THC can call but cannot receive or send text messages)
*
Your answer
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