Student Medical Appointment Request Form
Medical Health Services at The Health Center of Walla Walla
Reach us by email at:
Or by phone at: (509) 525-0704
Email address *
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 *
Student/Patient's Age *
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) *
Never submit passwords through Google Forms.
This form was created inside of The Health Center. Report Abuse