MEDICAL WITHDRAWAL LETTER
In support of a request to withdraw from a term or from courses

[Practice name]
[Address]
[Phone and email]

Date: [Date you write the letter]
To: [Registrar, dean's office, or appeals committee], [College or university]

Re: [Student's full name]
Date of birth: [Date]
Student number: [If the student gave it; otherwise delete this line]
Term: [Term and year, with its first and last day of classes]
The student is asking for: [Withdrawal from all courses, or from the courses they name, and any refund or grade review they are requesting]

The student asked for this letter and agreed to what it shares.

MY CARE OF THE STUDENT
First saw them for this: [Date, and in person or by video]
Since then: [Number of visits, how often, and the most recent date]
What I can't confirm: [The period before I first saw them, or nothing]

TIMELINE
Began or worsened: [Date or week of the term, and whether I observed it or the student reported it]
After the term started: [Yes, and what changed, or not applicable]
Last date the student could take part in classes: [Date, if known]
Unable to study from: [First date] to: [Last date, or the end of the term]

EFFECT ON STUDY
[What the student couldn't do in that period, such as attend, concentrate, sit exams, or hand in work, in plain words]
Withdrawing on time: [Why they couldn't withdraw by the deadline, if that applies; otherwise delete this line]
Courses affected: [All of them, or for a partial withdrawal, why some courses were affected and others weren't]

NOW
Care in place: [Treatment and support in general terms, and the next review date]
Return to study: [Fit to resume from a date or term, a lighter course load advised, or to be reassessed on a date]

DIAGNOSIS
[Not included, or with the student's consent: the diagnosis or a plain description they agree to]

I have described my assessment and the dates. Decisions on the withdrawal, grades, and any refund rest with the school.

[Your name, credentials]
[License or registration number]
[Signature]

To verify this letter: [Practice phone]