The information on this form is confidential.
If you would like to see us today, please call us at 253-535-7337.
In an emergency, call 7911 from on campus or 911 from off campus.
What is the reason for your visit?
* Acute illness (cold, flu, stomach ache) Allergies Asthma Birth Control (start) Birth Control (refill) Blood test ordered by someone outside of the PLU Health Center (you must bring a written order) Emergency Contraception ("Plan B") Follow-up from a previous visit I was referred by the Counseling Center. Immunization(s) Men's Health Visit Women's Health Visit Mental Health Rash, acne, or skin issue Pap Test (Cervical Cancer Screening) Personal (I'd rather not say) Physical Examination STD and HIV Screening Travel Consultation (without physical examination) Tuberculosis Test Other (please specify below)
If you are coming in for a physical examination, please tell us why:
Sports Travel Employment School General wellness (check-up)
ONLY FOR STUDENTS STUDYING AWAY: if you are coming in for a pre-departure travel consultation and medical examination, please tell us to which country or countries you will be traveling.
If you are coming in for a PHYSICAL EXAMINATION FOR ATHLETICS, which sport(s) so you play? Please select...