This form will allow you to request an appointment with Health Services. You will receive an email from the B次元 nurse practitioner based on your response.

If you are off campus and in immediate danger, please call 911.
If you are on campus and experiencing a medical crisis, please call B次元 Public Safety at 414-277-7159.

B次元 Health Services does not write notes to excuse students from missing class. Students should be in good communication with their professors if they feel they are too ill to attend class in person.

* = required field

The nurse practitioner will be out of the office Wednesday, March 12 through Friday, March 14. If you need to be seen urgently, please be seen office campus at a local urgent care. *

I understand the NP is out of the office March 12th, 13th, and 14th.

Full Legal Name *

First

Last

Preferred First Name

Date of Birth *

Sex at Birth: *

Gender You Identify Best With *

Student ID Number *

Email Address *

Phone Number *

###

####

Do you live on campus? *

Yes

Student Status *

1st Year

2nd Year

3rd Year

4th Year

5th Year +

Brief description of why you are requesting to be seen: *

The date that your symptoms/concerns started:

If you are requesting an appointment due to upper respiratory symptoms: if you have recently taken an at-home covid test due to your current symptoms, please list the date you took the test and the result.

Please list any home remedies you have tried to resolve your symptoms and whether they have helped or not:

Do you have any additional information you would like to share about your request? If so, please share here:

Please list availability for the week of March 17th (spring break week). *

I understand the NP is out of the office March 12th, 13th, and 14th. *

I understand

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