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  • Refusal of Treatment Form

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    brownboomerang
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    This document is a refusal of treatment form for a patient who has been recommended for a test, treatment, or procedure by their doctor. It includes spaces for the patient's name and contact information, as well as the recommending doctor's name. The form acknowledges that the patient has been informed of their medical condition, the purpose and nature of the recommended treatment, risks and benefits, alternatives, and that all their questions have been answered. It notes potential risks of refusing treatment, including delayed diagnosis and impaired health. Though refusing treatment could seriously harm their health or result in death, the patient chooses to refuse and accepts the risks, but may change their decision by contacting the doctor. The form requires signatures from the patient, a witness,

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    form

    Original Title

    Refusal

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    This document is a refusal of treatment form for a patient who has been recommended for a test, treatment, or procedure by their doctor. It includes spaces for the patient's name and contact information, as well as the recommending doctor's name. The form acknowledges that the patient has been informed of their medical condition, the purpose and nature of the recommended treatment, risks and benefits, alternatives, and that all their questions have been answered. It notes potential risks of refusing treatment, including delayed diagnosis and impaired health. Though refusing treatment could seriously harm their health or result in death, the patient chooses to refuse and accepts the risks, but may change their decision by contacting the doctor. The form requires signatures from the patient, a witness,

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    65 views1 page

    Refusal of Treatment Form

    Uploaded by

    brownboomerang
    This document is a refusal of treatment form for a patient who has been recommended for a test, treatment, or procedure by their doctor. It includes spaces for the patient's name and contact information, as well as the recommending doctor's name. The form acknowledges that the patient has been informed of their medical condition, the purpose and nature of the recommended treatment, risks and benefits, alternatives, and that all their questions have been answered. It notes potential risks of refusing treatment, including delayed diagnosis and impaired health. Though refusing treatment could seriously harm their health or result in death, the patient chooses to refuse and accepts the risks, but may change their decision by contacting the doctor. The form requires signatures from the patient, a witness,

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    REFUSAL OF TREATMENT FORM

    ______________________________
    Patient Name

    _______________________
    Date of Birth

    ______________________________
    Relationship to Patient

    _______________________
    Patient Phone number

    Dr. ____________________ has recommended that I undergo the following test/ treatment/ procedure:
    _____________________________________________________________________________________
    _____________________________________________________________________________________
    _____________________________________________________________________________________
    I acknowledge the following:
    1. My medical condition has explained to me by my physician
    2. The reason for and/or the purpose of the recommended test/ treatment/ procedure have been
    explained to me
    3. The nature of the recommended test/ treatment procedure has been explained to me
    4. The risks and benefits of the recommended test/ treatment/ procedure have been explained to
    me
    5. The alternatives (including non-treatment) to the recommended test treatment/ procedure
    have been explained to me
    6. All of my questions about the recommended test/treatment/ procedure have been answered to
    my satisfaction
    The risks of refusing the recommended test/treatment/procedure have been explained to me. They
    include, but are not limited to:
    Potential delay in diagnosis and treatment of health conditions.
    I also understand there could be risks of refusing the recommended test/treatment/procedure that are
    not yet known. Although my refusal to follow Dr. _________________ advice and undergo the
    recommended Test/treatment/procedure could seriously impair my health or even result to death, I
    choose to refuse the recommended test/procedure/treatment and accept the risks and consequences
    of my decision. I understand that I could change this decision at any time by contacting Dr. _________s
    office and taking action to cancel this refusal.
    ______________________________________________________________________
    Patient Name/ Representative
    Date
    ______________________________________________________________________
    Witness Signature
    Date
    ______________________________________________________________________
    Physician Signature
    Date

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