Appointment Request

First Name * Last Name * Date of Birth * Gender * Home Address * City * Province * Postal Code * Phone Number Health Card # * Student Number * Email Address *

Are you a New Patient? * Yes No

Health Concern (please limit to 1 concern only, max 250 characters) *

Appointment Date/Time Options

Due to limited appointment spots, we may not be able to guarantee your preferred time. However, selected choices will be considered and the clinic will contact you via phone or email to schedule you.

Please make each choice on a different day.

First Day Choice * First Time Choice *

Second Day Choice * Second Time Choice *

Third Day Choice * Third Time Choice *

Emergency Contact Information

Contact Name * Relationship * Contact Phone *

The University of Regina collects information under the authority of The University of Regina Act and in accordance with the Local Authority Freedom of Information and Protection of Privacy Act and the Personal Information Protection and Electronic Documents Act for purposes of the administration of the University and its programs and services. By responding to this form, you are consenting to the University of Regina using your personal information to respond to your request.

You will receive an email confirming your appointment date and time.

If you need to cancel your appointment, please contact the clinic at 306-337-2200 or email us at student.wellness@uregina.ca at least 24 hours in advance.

If you arrive 10 minutes late, you will need to reschedule your appointment for another day.