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Medical Withdrawal through Health Service Eastern Illinois University Health Service 600 Lincoln Ave, Charleston, IL 61920 Phone: (217) 5813013 FAX: (217) 5813899 www.eiu.edu/health This form outlines
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01
Start by entering your personal information, including your full name, date of birth, and contact details.
02
Next, provide information about the healthcare provider or institution involved. This includes their name, address, and contact information.
03
Indicate the reason for your medical withdrawal. This could include a medical condition, injury, or other relevant circumstances.
04
Specify the date of the withdrawal and the expected duration of the withdrawal.
05
Describe any relevant medical treatments or interventions that are currently being received or have been received in the past.
06
Discuss any potential risks or complications associated with the withdrawal, as well as any alternative options that have been considered.
07
Sign and date the consent form. Make sure to read the entire document carefully before signing.

Who needs medical20withdrawal20consent20-revised20september202015doc - eiu:

01
Any individual who needs to withdraw from medical treatment or care.
02
Patients who wish to discontinue a particular medical procedure or intervention.
03
Individuals who want to communicate their consent and understanding of the potential risks involved in the medical withdrawal process.
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This document is a revised form for medical withdrawal consent as of September 20, 2015.
The individual seeking medical withdrawal is required to fill out and submit this form.
The form should be completed with accurate information regarding the medical withdrawal consent and signed by the individual seeking withdrawal.
The purpose of this form is to provide consent for a medical withdrawal from a particular program or situation.
The form should include personal details, reason for withdrawal, date of withdrawal, and signature of the individual.
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