Medical Withdrawal Request to Return-Healthcare Provider Report
Purpose: this form is used when a student wishes to return to Marquette after an official medical withdrawal from the University and is completed by the student's healthcare provider.
"Healthcare Provider" means Licensed Healthcare Provider (e.g. MD, DO, Psychologist, Licensed Clinical Social Worker, etc.).
Section 1: Student Information
@marquette.edu
Student Instructions:
1. Complete Section 1 of this form using a computer.
2. Print the form using the 'Print Form' button.
a. a handwritten form will not be accepted.
b. an incomplete form will not be processed and will be returned to you for completion.
3. Sign the form in Section 2; a digital signature is not acceptable.
4. Submit this form to your healthcare provider at least 6 weeks prior to your planned return to the University.
Note: both the Medical Withdrawal-Return to Marquette University form and the Request for Readmission form must be completed and submitted in order for your return request to be considered.
Healthcare Provider Instructions:
1. Complete Sections 3 and 4 of this form.
2. Sign the form in Section 5.
3. Return the original form via one of the methods listed at the bottom of this form within 4 weeks of the student's planned return to the University.
Note:
a. An unsigned form with not be processed.
b. This form must come directly from the Healthcare Provider (not the student) or it will not be accepted.
Rev. 11/2016
Section 3: Licensed Healthcare Provider Information
DateStudent's Signature
Section 2: Student Statement and signature:
I certify that the information provided above is true and correct.
Section 4: Licensed Health Care Provider Report
Date of first treatment contact Date of most recent treatment contact
Diagnosis for which the student is being treated (i.e. description)
Page 1 of 2
Please use the back of this page or attach additional documentation if you wish to expand on your responses to the questions above and/or to record any other comments or
observations you may wish to make regarding the student and his/her ability to function safely, stably, and successfully as a full-time student at this time.
EmailPhone
Date of expected return to Marquette MM/DD/YYYY
Name License Number and State
Licensed as Clinic/Hospital Name
Mailing Address
Phone Fax
Hand Deliver: Marquette Central, Zilber Hall, 121, 1250 West Wisconsin Avenue, Milwaukee, WI 53233
Mail: Marquette University, Zilber Hall, 221, P.O. Box 1881, Milwaukee, WI 53201-1881
Email: otrdocs@marquette.edu
MUID
Name
Last name, First name, Middle name
Mailing Address
street, city, state, zip code
