Student Medical Appointment Request Form

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Medical Health Services at The Health Center of Walla Walla
Reach us by email at: help@thehealthcenterww.org

Email *

Name of Person Completing this Request *

Relationship to student: *

Self

Parent/Guardian

School Health Provider

Other:

Last Name of Student/Patient *

First Name of Student/Patient *

Student/Patient's Date of Birth *

YYYY

Appointment Request Type *

In person (for Sports physicals and Vaccine administration)

Telehealth (Limited to visits that do not require a lab test or physical assessment)

Other:

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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