Consent Form for Againt Medical Advice (Eng)

Consent Form for Against Medical Advice

Time *
:
I am a *
State the reason the patient is not able to give consent personally (or to self sign on this form) *
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: *
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.