HOSPITAL __________________________

TESTIMONIAL LETTER OF REFUSAL OF TREATMENT/PROCEDURE PER/REFUSE/2016

I, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ IC/ID No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ,
*patient/parent/spouse/son/daughter/guardian/relative of the patient _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
IC/ID No. _ _ _ _ _ _ _ _ _ _ _ _ _ refuse the treatment/procedure of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
for *me/the patient. I have been given detailed explanation of the treatment/procedure including the
purpose and benefit(s).

I have also been explained and understand the possible risk(s) if the treatment/procedure is not
performed.

Signature :__________________ Signature of translator: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(*Patient/Parent/Spouse/Son/Daughter/Guardian/Relative, (if any)
state relationship : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ) Name of translator: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address :__________________ IC/ID No. :__________________
__________________ Date :__________________
Tel. No. :__________________ Language used : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date :__________________

Signature of Doctor : _ _ _ _ _ _ _ _ _ _ _ _ _ _ Signature of witness: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Name of Doctor: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Name of witness: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
MMC/MDC No.: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ IC/ID No. :__________________
Date :_________________ Designation :__________________
Stamp : Date :__________________
I confess that this decision was made on my own free will. I shall be fully responsible for any
possible consequence(s) arising from this action.

I affirm that I will not take any legal action upon the hospital or any other relevant parties should
there be any unfortunate outcome resulting from this decision.

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