Forms and Documents

On this page, you’ll find useful forms and documents relating to health care at the Klotz Student Health Center. This information will be helpful for students who are under 18 years old when they attend CSUN, students who would like a copy of their medical records or who need to withdraw from classes for medical reasons. Select one of the below options to find out more. 

Students can access and complete new patient forms including: SHC Acknowledgement of Fees, SHC Health History, SHC Notice of Privacy Practices and SHC Treatment Agreement though the myhealth portal.

Consent for Treatment of Minors

General Consent to Disclose/Release of Information

Petition for Withdrawal for Medical Reasons


Academic Withdrawals for Medical Reasons

Medical withdrawals from the university are taken on a case-by-case basis and are reviewed by the director of the Klotz Student Health Center. To ensure your medical withdrawal processes correctly, please read through these guidelines and contact the appropriate campus staff.

Undergraduate students

If you need to withdraw from classes for a medical reason, please contact the Office of Undergraduate Studies in University Hall 215 or call (818) 677-2969.

Graduate students

Per Executive Order 1037:

6.d. Withdrawals after the census date and prior to the last 20 percent of instruction may be assigned only for serious and compelling reasons. Permission to withdraw during this time shall be granted only with the approval of the instructor and the department chair and/or dean as described by campus policy. All requests to withdraw under these circumstances and all approvals shall be documented as prescribed by the campus. The requests and approvals shall state the reasons for the withdrawal. Records of such approvals shall be maintained in accordance with the campus record retention policy.

6.e. Withdrawals shall not be permitted during the final 20 percent of instruction except in cases, such as accident or serious illness, where the cause of withdrawal is due to circumstances clearly beyond the student's control and the assignment of an Incomplete is not practicable. Requests for permission to withdraw under these circumstances shall be handled and filed as indicated in the preceding paragraph, except that such requests must also be approved by the academic administrator appointed by the president to act in such matters.

For necessary forms and more in-depth information, see the graduate withdrawals policy.

Complete or partial medical withdrawals

A medical withdrawal usually constitutes complete withdrawal from the university for the academic period in question. Requests for complete medical withdrawals should be submitted as soon as possible after the medical condition impairs the student’s ability to complete the coursework for which the student is registered. An authorized representative of the student may also submit the request.

Requests for conditions or circumstances that arise during the final three weeks of instruction or thereafter will only be considered in cases of severe illness or injury. Petitions requesting retroactive withdrawals beyond one year after the conclusion of the semester for which the withdrawal is requested will not be considered.

Graduate Students who wish to apply for a possible withdrawal for medical reasons after the census date may contact the Office of Graduate Studies at (818) 677-2138 or may contact the Klotz Student Health Center assistant to the director, Sylvia Freiberg, at (818) 677-3691.

To apply for a withdrawal for medical reasons

  • Please fill out the Withdrawal application form for Graduate Students. As noted in the form, you will need a signed letter on letterhead from your health care provider that supports your application.
  • Bring the completed application and letter to Room 242 in the Student Health Center and give it to Sylvia Freiberg. She will arrange for Dr. Yolanda Chassiakos, the director, to review your application. If your reason for a medical withdrawal is approved as valid, you will be given an approval form by Sylvia to take to your instructor(s), department administrator (dean or associate dean) and the interim associate vice president of graduate studies for the required signatures.

Additionally, it is important that graduate students understand the following.

  • Withdrawals for medical reasons may affect a student's academic status. Please contact Admissions and Records at (818) 677-3700, option seven.
  • The Klotz Student Health Center does not handle refunds. Questions about possible refunds should be directed to Student Financial Services at (818) 677-2310.
  • Withdrawals for medical reasons may affect a student's financial aid. Students are encouraged to contact the Financial Aid & Scholarship Department at (818) 677-4085, option five.
  • International students, a withdrawal may affect your student visa. Please contact the International and Student Exchange Center at (818) 677-3053 before you submit your application.
  • Veterans, a withdrawal may affect your veterans' benefits. Please contact Veteran Student Services at (818) 677-5928 before you submit your application.
  • To ensure their health and safety, some students granted a medical withdrawal will require written clearance from their health care provider to return to school. This clearance should be provided prior to registration to Sylvia in the Klotz Student Health Center, Room 242.

The application form for the graduate student withdrawal for medical reasons is found here.