Clinic Cancellation Form

Please fill out the form to request a clinic closure. Please remember that any requests received with less than 30 days notice are subject to approval.

Submitted By
Provider Name
Date Requsted (mm/dd/yyyy)
Clinic Date Start Range (mm/dd/yyyy)
Clinic Date End Range (mm/dd/yyyy)
Reason for Cancellation
Service Location
Was a new session added to accommodate bumped patients?    Yes
Can another faculty member cover this clinic?    Yes
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