About Hours and LocationMake an AppointmentMeet the StaffFormsGrievance Procedures Services Our ServicesMake an AppointmentEligibility & General InformationClinic ChargesWomen's Health CareSexual HealthSexually Transmitted Infection Testing & TreatmentRespiratory IllnessesNarcan Dispensers Date(Required) MM slash DD slash YYYY Student Name(Required)This acts as your legal and binding signature and indicates that all of the information provided is factual to the best of your knowledge.Student ID / T#(Required) Email Address (so we can notify you when your form is ready for pickup).(Required) Name of Study Abroad Program/Country:(Required)Do you have asthma or have you ever experienced an induced asthma attack?(Required) No Yes Do you have any known allergies to food, plants, insect stings, bites, or animal hair?(Required) No Yes Do you take any medications on a regular basis?(Required) No Yes Do you have any other condition(s) that might compromise your ability to fully participate in a study abroad program?(Required) No Yes Females Only: Are you pregnant? If you are pregnant, clearance must be obtained through your Ob/Gyn. Yes No Females Only: Date of last menses:CaptchaEmailThis field is for validation purposes and should be left unchanged.
