Program Manual - Saint Louis University

Graduate Program in Orthodontics
LEAVE OF ABSENCE FORM
Resident's Printed Name Date of Request
This form has been completed to initiate a request for a Leave of Absence from the Orthodontic Program
for the period:
My reason for requesting this is as follows:
Absence From Clinic
To
Because I am going to be absent from the clinic, I request that my patients be rescheduled. It is the
determination of the Clinic Supervisor that this schedule change will not place an undue burden on the
staff.
Clinic Supervisor's Printed Name Clinic Supervisor's Signature
Alternately, my schedule will be maintained and a substitute resident will see my scheduled and emergency
patients, and provide care and treatment under supervision by the appropriate faculty members.
Substitute Resident's Printed Name Substitute Resident's Signature
It is the assessment of the Clinic Director that this change in my clinic schedule will not have a negative
impact on my patients.
Clinic Director's Printed Name Clinic Director's Signature
Absence From Classes
While away from the Program, I will miss the following classes. Approvals for all missed courses have
been obtained as indicated below:
Course Instructor's Signature
Course Instructor's Signature