NY Campus: The clinic will reopen on Monday, July 22nd at 9am. All clinic shifts will be on the 19th floor.

Clinic Make-Up Shift Request Form

Clinic Make-Up Shift Request Form

  1. Instructions
  2. Student Information

    Please enter your information below.  Please ensure your email address is correct as confirmations will be sent to the email address you submit in the form.

    Please enter your first name

    Please enter your last name

    Please enter a valid phone number

    Please enter an @pacificcollege.edu email address

    Please select a campus

  3. Missed Shift Information

    Please enter the information for the shift you missed below.

    Please select a clinic level

    Please select a term

    Please enter a date

    Please select a missed shift clinic level

    Please select a time

    Please enter a supervisor’s name

    Please enter a reason for missing shift

  4. First Choice

    Pick date that will allow for at least 5 BUSINESS days to process

    Please select a valid time

    Please pick a different clinic shift than your second or third choice

  5. Second Choice

    Pick date that will allow for at least 5 BUSINESS days to process

    Please select a valid time

    Please pick a different clinic shift than your first or third choice

  6. Third Choice

    Pick date that will allow for at least 5 BUSINESS days to process

    Please select a valid time

    Please pick a different clinic shift than your first or second choice

  7. Comments

  8. Please check the box to confirm