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.

Largest insurer in the U.S.

OMIC is the largest insurer of ophthalmologists in the United States and we've been the only physician-owned carrier to continuously offer coverage in all states since 1987. Our fully portable policy can be taken with you wherever you practice. Should you move to a new state or territory, you're covered without the cost or headache of applying for new coverage.