Consent Form for Against Medical Advice

Date *

Time *

:

I am a *

Patient

Legal representative

Name - Surename *

Age *

Identification Number / Passport Number *

Name - Surename (Patient) *

Age (Patient) *

State the reason the patient is not able to give consent personally (or to self sign on this form) *

Under legal age of self-consent —patient with age not yet completing 20 year

Incompetent person/ qausi-incompetent person

Person with insanity in the mind

OtherOther

Relationship to the patient *

Name - Surename (Legal representative) *

Please upload your Identification card / Passport (Legal representative) *

Maximum upload size: 67.11MB

I hereby acknowledge and confirm that I have been fully and entirely informed by the physician(s) , nurse(s) and medical staff of BNH Hospital of the necessity of the medical investigations, treatments and surgeries; and, after my thorough and careful consideration,

I have the intention to: *

Refuse medication therapy

Refuse anesthesia and/or surgery

Refuse procedure

Refuse admission to the hospital for treatment or continuation of treatment at the hospital

Refuse to attempt Cardiopulmonary Resuscitation (Cardiopulmonary ResuscitatiOn an emergency procedure that combines chest compresSiOns often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest)

Refuse investigation

I have received information from the physician about the symptoms of the disease andtor injury that may jeopardize my health or life. The physician has explained to me the risks and benefits of the recommended treatment. I am choosing to leave BNH Hospital against medical advice and release BNH from any responsibility resulting from this decision.

I hereby refuse to receive the treatment detailed above *

Clear

I hereby refuse to receive the treatment detailed above *

Clear