Premed/Prehealth Appointment Request

Please provide as much information as possible when submitting this request form. An incomplete request may delay our ability to schedule your appointment.

Full Name:

Preferred Email Address:

Alternate Email Address:

Student ID:

Current Major:

NU Graduating Class:

Hometown and state (or state of residence, if permanent address is outside the US):

For Premed Freshmen: What date did you attend a Premed Workshop at the UAAC? (Note: All freshmen premed students must attend one Premed Workshop for Freshmen prior to scheduling an appointment with a premed adviser.)

                                            Date:   

Area of interest within the health professions (check all that apply):

Medicine (MD)
Medicine (DO)
Dentistry
Nursing
Physical Therapy
Physician Assistant
Public Health
Veterinary Medicine
Other

Brief overview of what you would like to discuss:

Preferred appointment date:

Please list at least four time ranges (ex: 10-3pm) between 9am and 4pm when you would be available to meet on the following days:

Monday

Tuesday

Wednesday

Thursday

Friday

How did you hear about our office?

Academic Adviser
Friend
Website
Parent/Guardian
Other

Would you like to receive the UAAC Weekly Update email, which details upcoming events and opportunities relevant to premed/prehealth students?

Yes, I would like to receive the weekly update email
No, I do not want to receive the weekly update email
I already receive the weekly update email