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Medical Withdrawal Form Template

Easily Manage Medical Withdrawals with Our User-Friendly Template

Facing a medical issue can disrupt your academic progress, but you don't have to navigate withdrawal alone. This Medical Withdrawal Form Template is designed to help students like you submit a clear and efficient application for withdrawal due to illness or injury. With this template, you'll benefit from streamlined communication with your institution, quick processing of your request, and peace of mind knowing your rights are respected-plus, it aligns with WCAG standards for accessibility. Explore the live template now to simplify your medical withdrawal process.

Use this Template (FREE) Live Preview
Full name
Student ID number
Email address
Mobile phone number
Institution name
Date of birth
Type of medical withdrawal requested
Full withdrawal from all courses this term
Partial withdrawal from selected courses
Retroactive medical withdrawal
Not sure
Term and year (e.g., Fall 2025)
Requested effective date of withdrawal
Courses to withdraw from (list course codes and titles; if full withdrawal, enter "All courses")
Briefly describe how your medical condition has impacted your ability to participate in coursework
Date symptoms began or worsened
Do you have supporting medical documentation available now?
Yes
No
How will you submit your documentation?
Email to designated office
Upload to secure portal
In person drop-off
By mail
Not sure
Healthcare provider full name
Provider type
Physician (MD/DO)
Psychiatrist
Psychologist
Therapist/Counselor
Nurse Practitioner
Physician Assistant
Prefer not to say
Other
Please Specify:
Facility or clinic name
Provider phone number
Most recent treatment date
Do you consent to the institution contacting your provider solely to verify documentation?
Yes
No
I understand that a medical withdrawal may affect financial aid, billing, housing, athletic eligibility, and visa status, and I am responsible for consulting the relevant offices.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I acknowledge that submitting this form does not guarantee approval and that required documentation must be received by stated deadlines.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Type your full legal name as signature
Signature date
I certify that the information provided in this request is true and complete to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration depicting a medical withdrawal form for the FormCreatorAI article

When to use this form

This template helps registrars, HR teams, and program managers handle requests to leave a course, rotation, or assignment for health reasons. Use it when a student must withdraw mid-term after surgery, or an employee needs to stop a shift schedule due to an injury. You collect dates, provider details, and consent in one place so you can decide fast and stay compliant. If the person was recently discharged, pair this with the Hospital discharge form. When you need to share records with another school or employer, add the Transfer of medical records form. Clear steps reduce back-and-forth and set expectations for refunds, grades, benefits, and any return-to-work plan.

Must Ask Medical Withdrawal Questions

  1. What is the medical reason for your withdrawal, as documented by a licensed provider?

    This clarifies eligibility and risk and helps route the request to the right team. If staff must verify documentation quality, use the Medical record audit form.

  2. What is your last date of participation, and when did your condition start affecting attendance or performance?

    Accurate dates support fair refunds, grades, and leave benefits. Clear timing also helps coordinators plan coverage and deadlines.

  3. Which courses, shifts, rotations, or program components are you withdrawing from?

    This detail prevents partial or incorrect changes. It lets each department close records and update systems without delays.

  4. Do you authorize release of relevant medical information to the named school, employer, or insurer?

    Consent is required to share only what is needed. It speeds decisions while respecting privacy laws.

  5. Do you intend to return, and if so, what date or conditions would allow it?

    This guides make-up work, grading holds, or staffing. If return depends on a provider note, reference an Urgent care work release form.

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