Student Medical Appointment Request Form
Medical Health Services at The Health Center of Walla Walla
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Email *
Name of Person Completing this Request *
Relationship to student: *
Last Name of Student/Patient   *
First Name of Student/Patient *
Student/Patient's Date of Birth *
Appointment Request Type *
Reason for appointment (Chief Complaint).  If requesting vaccine list which one(s).   *
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. *
Name of School Student/Patient attends *
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) *
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