AGAINST MEDICAL ADVICE (AMA FORM) - The Sullivan Group
AGAINST MEDICAL ADVICE (AMA FORM)
This is to certify that I, ________________________________________, a patient at __________________________________________(fill in name of your hospital), am refusing at my own insistence and without the authority of and against the advice of my attending physician(s) _______________________________________, request to leave against medical advice.
The medical risks/benefits have been explained to me by a member of the medical staff and I understand those risks.
I hereby release the medical center, its administration, personnel, and my attending and/or resident physician(s) from any responsibility for all consequences, which may result by my leaving under these circumstances.
MEDICAL RISKS
_____Death
_____Additional pain and/or suffering
_____Risks to unborn fetus
_____Permanent disability/disfigurement
_____Other:___________________________________________________ _____________________________________________________________ _____________________________________________________________
MEDICAL BENEFITS
_____ History/physical examination, further additional testing and treatment as indicated.
_____ Radiological imaging such as: _____CAT scan ____X-rays ____ ultrasound (sonogram)
_____ Laboratory testing _____ Potentional admission and/or follow-up _____ Medications as indicated for infection, pain, blood pressure, etc. _____ Other:____________________________________________
Please return at any time for further testing or treatment
Patient Signature_______________________ Date_______________
Physician Signature_____________________ Date_______________
Witness ______________________________ Date_______________
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