Risk Management

Refusal of Recommended Medical or Surgical Treatment


Patient Name:

Dr. ___________ informed me of the following:

I have the following condition(s):
The doctor recommends:
The recommended treatment consists of:
The purpose of the recommended treatment is:

I should get the recommended treatment within the following time period:
The possible alternative(s) to the recommended treatment:
The consequences of not getting the recommended treatment or the above described alternative(s):

I understand that my failure to accept the recommended treatment may endanger my vision, life, or health; I nonetheless refuse to consent to it.

My reason for refusal is:


Patient (or person authorized to sign for patient)                Date

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