Medical Withdrawal Form

Medical Withdrawal Form

To be completed by the student's treating physician, psychiatrist, psychologist, or similar.

This form must be submitted within two weeks of notifying The Swedish Program of the intent to withdraw for medical reasons.

Healthcare Provider Details

Your name*

PrefixFirstLast

Your title*

Your email*

Your phone number*

Your practice/office address*

Street Address 1

Street Address 2

CityState

Zip Code

Student Details

Student's name (the patient)*

First NameLast Name

What is the student's medical diagnosis or condition?

Approximate date of onset

Please describe the symptoms or medical restrictions that significantly impact the student’s ability to participate in a study abroad program and any additional medical information that may be relevant for the student’s request for medical withdrawal.

Signature*