College of the Sequoias | Complete Appointment Request

Banner ID:

First Name:

Last Name:

Email:*

This is the email address we have on file. If you would like to be contacted through a different address, please change this field.

Confirm Email Is Correct:*

Yes

Contact Phone:*

What health service would you like to schedule? (Check as needed):*

Mental Health Counseling
Nurse Assessment (illness/injury/OTC medication)
TB Test
Immunizations
Pregnancy Test
Sexually Transmitted Disease Testing
Food Pantry Assistance
CalFresh Sign-ups
Case Management

Choose campus health center where you prefer to be seen:*

VisaliaHanfordTulare

Some appointments may be done through tele-health/virtual platform. Would you be willing to use this format?:*

YesNo

Perferred Day(s) of the Week:

MonTueWedThurFri

Perferred Time(s):

Early Morning
Late Morning
Early Afternoon
Late Afternoon

By clicking the Submit button below, I hereby give consent to College of the Sequoias to process any healthcare information submitted through cos.edu. Any questions regarding this consent can be directed to me using the email address that I have provided above, in this form.

COS

Complete Appointment Request

AE Form Web Part

COS

Complete Appointment Request

AE Form Web Part

Please stop and read the following message before continuing to the Noncredit application! If you complete this noncredit application you will not be able to register for a credit course.

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