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Against Medical Advice (Ama Form)

This form certifies that a patient named __________________ is refusing medical treatment and choosing to leave the hospital against the advice of their attending physician. By signing the form, the patient acknowledges being informed of the medical risks of leaving such as death, additional pain/suffering, or permanent disability. They also release the hospital and medical staff from any responsibility for consequences of their decision. The form lists potential medical risks and benefits of staying for further examination and treatment.

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aloknsingh
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2K views

Against Medical Advice (Ama Form)

This form certifies that a patient named __________________ is refusing medical treatment and choosing to leave the hospital against the advice of their attending physician. By signing the form, the patient acknowledges being informed of the medical risks of leaving such as death, additional pain/suffering, or permanent disability. They also release the hospital and medical staff from any responsibility for consequences of their decision. The form lists potential medical risks and benefits of staying for further examination and treatment.

Uploaded by

aloknsingh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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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