Student Experience Request Form

To be considered, please fill out the form below. You must email your immunization record and acknowledgment form (found below). If you are under 18 years old, you must have a parent or guardian sign the Student Experience Request Form.

Immunization Required – Email documents to students@mahealthcare.com

• Required immunizations:
  • MMR
  • Varicella
  • Hepatitis B
  • Tdap
  • TB within the last 12 months
  • Influenza within the last year (needs to be within current flu season if rotating October-March)
  • COVID-19 (if accompanying provider to MercyOne Dubuque Medical Center)