RELEASE REFUSAL TO PERMIT ELECTRONIC FETAL MONITORING I, ________________________________________ (Name and Address), a patient at ____________________________________________ (Name of Hospital) have been advised by Dr. ________________________ as to the advisability of and the dangers attendant to electronic fetal monitoring. I understand that information obtained through electronic fetal monitoring may permit timely and appropriate medical care to be given to both mother and child, which might prevent infant death or brain damage. Despite this information, I have chosen to refuse to have electronic fetal monitoring. My decision is made with full realization that my baby could have problems, including very serious conditions, that may go undetected without electronic fetal monitoring. I release Dr. ___________________, the hospital, its personnel, severally and individually, from responsibility and any liability for undesired consequences resulting from this refusal to permit electronic fetal monitoring.
_____________________________ Signature of Mother _____________________________ Signature of Father
__________________ Date __________________ Date
_____________________________ Witness
___________________ Date