REFUSAL TO PERMIT MEDICAL TREATMENT AND/OR OPERATION
REFUSAL TO PERMIT MEDICAL TREATMENT
___________________________________ (name of hospital) I, _____________________________________________ (name), being a patient at ___________________________________ (name of hospital) have been advised by Dr. ____________________, my attending physician, as to the advisability of, the risk and complications inherent in, the expected benefits of, as well as the alternatives to and their risks and benefits, and the probable consequences of not receiving the following medical treatment or operation: ____________________________________ (describe medical treatment or operation).
I have requested, against the advice of Dr. ________________________, my attending physician, that the above-described ____________________ (treatment or operation) should not be administered to me during my stay at ____________________________ (name of hospital), and I release Dr. ___________________________, the hospital, its personnel, severally and individually, from any liability of any nature for any injury or complication of any kind that may result, directly or indirectly, by reason of my refusal to permit the above-mentioned _______________________ (treatment or operation), and I waive all rights of action I may now have or later acquire as a result of this refusal.
This refusal is made by me with full knowledge that __________________________ ________________________________________________ (describe consequences).
_____________________________ (Signature of Patient) _____________________________ (Witness)
___________________ (Date) ___________________ (Date)
(If patient is a minor or for any reason is unable to sign refusal, a spouse, parent, guardian, or next of kin should sign below.)
I refuse to permit the medical treatment or operation described above.
_____________________________ (Signature)
___________________ (Date)
____________________ (Relationship to Patient)
_____________________________ (Witness)
___________________ (Date)