Waiver for Diet (Therapeutic Diet)
This is a sample. Please adjust as needed for your facility and print on facility letterhead.
Consult your facility attorney or risk management department.
Patient Name_______________________ Patient Date of Birth____________
Medical Record Number:_______________
I, ______________________________ understand that the doctor has ordered a special
diet. This diet is considered important to my health and is part of my treatment plan.
However, I prefer to make my own food choices and wish to decline the
__________________ diet that was prescribed. My questions about the diet have been
answered. I have been counseled on the risks and benefits of refusing the diet and accept
responsibility for any health condition that may result from refusal of the diet. I release
______________________(facility name) of liability regarding this decision to refuse the
Patient (or Responsible Party Date
Facility Representative Date