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    Against Medical Advice (Ama Form)

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    aloknsingh
    This form certifies that a patient named __________________ is refusing medical treatment and choosing to leave the hospital against the advice of their attending physician. By signing the form, the patient acknowledges being informed of the medical risks of leaving such as death, additional pain/suffering, or permanent disability. They also release the hospital and medical staff from any responsibility for consequences of their decision. The form lists potential medical risks and benefits of staying for further examination and treatment.

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    Download as PDF, TXT or read online from Scribd

    Against Medical Advice (Ama Form)

    Uploaded by

    aloknsingh
    728 views1 page
    This form certifies that a patient named __________________ is refusing medical treatment and choosing to leave the hospital against the advice of their attending physician. By signing the form, the patient acknowledges being informed of the medical risks of leaving such as death, additional pain/suffering, or permanent disability. They also release the hospital and medical staff from any responsibility for consequences of their decision. The form lists potential medical risks and benefits of staying for further examination and treatment.

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    Against Medical Advice to be filed in hospital

    Original Title

    AMA_form

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    This form certifies that a patient named __________________ is refusing medical treatment and choosing to leave the hospital against the advice of their attending physician. By signing the form, the patient acknowledges being informed of the medical risks of leaving such as death, additional pain/suffering, or permanent disability. They also release the hospital and medical staff from any responsibility for consequences of their decision. The form lists potential medical risks and benefits of staying for further examination and treatment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    728 views1 page

    Against Medical Advice (Ama Form)

    Uploaded by

    aloknsingh
    This form certifies that a patient named __________________ is refusing medical treatment and choosing to leave the hospital against the advice of their attending physician. By signing the form, the patient acknowledges being informed of the medical risks of leaving such as death, additional pain/suffering, or permanent disability. They also release the hospital and medical staff from any responsibility for consequences of their decision. The form lists potential medical risks and benefits of staying for further examination and treatment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    AGAINST MEDICAL ADVICE (AMA FORM)

    This is to certify that I, ________________________________________,


    a patient at __________________________________________(fill in name
    of your hospital), am refusing at my own insistence and without the authority
    of and against the advice of my attending physician(s)
    _______________________________________, request to leave against
    medical advice.
    The medical risks/benefits have been explained to me by a member of the
    medical staff and I understand those risks.
    I hereby release the medical center, its administration, personnel, and my
    attending and/or resident physician(s) from any responsibility for all
    consequences, which may result by my leaving under these circumstances.
    MEDICAL RISKS
    _____Death

    _____Additional pain and/or suffering

    _____Risks to unborn fetus

    _____Permanent disability/disfigurement

    _____Other:___________________________________________________
    _____________________________________________________________
    _____________________________________________________________
    MEDICAL BENEFITS
    _____ History/physical examination, further additional testing and treatment
    as indicated.
    _____ Radiological imaging such as:
    _____CAT scan ____X-rays ____ ultrasound (sonogram)
    _____ Laboratory testing _____ Potentional admission and/or follow-up
    _____ Medications as indicated for infection, pain, blood pressure, etc.
    _____ Other:____________________________________________
    Please return at any time for further testing or treatment
    Patient Signature_______________________

    Date_______________

    Physician Signature_____________________

    Date_______________

    Witness ______________________________

    Date_______________

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