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 gettung the recommended treatnent 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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Six reasons OMIC is the best choice for ophthalmologists in America.

#6. Supporting your specialty.

OMIC was founded by members of the American Academy of Ophthalmology nearly a quarter century ago and is the only carrier sponsored and endorsed by AAO. OMIC is also endorsed by 40 other ophthalmic societies. The OMIC partnerships with state and subspecialty societies qualifies their members for an exclusive 8% premium credit. Contact your state society for details.