Morningside College
Student Health Services

Date Of Service:

Arrival Time:

Check One:   Walk-in    Appointment

Is this your first Health Center visit?   Yes    No

How long did you wait for assistance after your arrival at the Health Center?

Student Type:   Traditional    Continuing Education

Gender:   Female Male          Student Class:   Freshmen Sophomore Junior Senior Graduate

Are there any other services that you would like the Health Center to offer?

General comments and suggestions:

If you would like to be contacted by the Health Center please include your name and phone number.

Name:

Phone: