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This form documents a patient leaving a hospital against medical advice. It requires signatures from the treating doctor, patient, and witness. The doctor must explain the proposed treatment, risks of leaving, and treatment alternatives. The patient confirms being informed of medical risks and that they take responsibility for any consequences of their decision. If the patient refuses to sign, a hospital employee must witness it. Copies are kept in the patient file and sent to the patient's general practitioner.

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LOVI KRISSADI
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497 views

Form Ama PDF

This form documents a patient leaving a hospital against medical advice. It requires signatures from the treating doctor, patient, and witness. The doctor must explain the proposed treatment, risks of leaving, and treatment alternatives. The patient confirms being informed of medical risks and that they take responsibility for any consequences of their decision. If the patient refuses to sign, a hospital employee must witness it. Copies are kept in the patient file and sent to the patient's general practitioner.

Uploaded by

LOVI KRISSADI
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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SELF-DISCHARGE AGAINST MEDICAL ADVICE FORM

TO BE COMPLETED BY THE DOCTOR


I, the undersigned, Mr., Mrs. Ms…………………………………………………………………practising
as…………………………………………at Périgueux Hospital, confirm that Mr., Mrs, Ms (surname, first name,
date of birth) :
…………………………………………………………………………………………………………………………..
declines the proposed treatment and declares s/he wishes to leave the establishment.
I have explained the potential medical risks of this action to the patient in a clear, precise and
comprehensible manner and the therapeutic alternatives.
 Description of patient’s state of health:…………………………………………..
…………………………………………………………………………………………………
…………………………………………………………………………………………………
 Treatment proposed by the doctor:…………………………………………..
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
 Medical risks linked to the patient’s premature departure:……………………………..
………………………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………………………….
…………………………………………………………………………………………………..
 Other information given (offer of follow-up consultation, possibly with another doctor, proposed
transfer to another establishment, proposal to take time to consider the options:
………………………………………………………………………………….
………………………………………………………………………………………………..
……………………………………………………………………………………………….
Date : Doctor’s signature:

Time :

TO BE COMPLETED BY THE PATIENT


I, the undersigned, Mr., Mrs., Ms. : ……………………………………………………………………………………..
currently a patient at Périgueux Hospital, decline the treatment proposed by
Doctor…………………………………… and wish to leave the establishment.
I confirm that I have been informed of the potential medical risks of leaving against medical advice in a clear,
precise and comprehensible manner.
I confirm that I have taken this decision of my own free will and that it is against medical advice. I therefore
absolve the doctor and the hospital of all liability and any consequences that may arise from my decision.
I understand that even if I sign this document, this does not prevent me from coming back to the hospital
should I so wish and that, indeed, this is strongly recommended should I have any questions or the slightest
problem.

Date: Patient’s (or legal representantive’s signature:

Time:

If the patient refuses to sign:


Name and signature of a witness employed by the hospital:

Original to be kept in the patient’s file


1 copy to be given to the patient
1 copy to be sent to the patient’s general practitioner

Direction des Usagers 2016 Self-Discharge Against Medical Advice Form CHP Ref 7592 Version 01
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