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Refusal of Treatment Form

This document is a refusal of treatment form for a patient who has been recommended for a test, treatment, or procedure by their doctor. It includes spaces for the patient's name and contact information, as well as the recommending doctor's name. The form acknowledges that the patient has been informed of their medical condition, the purpose and nature of the recommended treatment, risks and benefits, alternatives, and that all their questions have been answered. It notes potential risks of refusing treatment, including delayed diagnosis and impaired health. Though refusing treatment could seriously harm their health or result in death, the patient chooses to refuse and accepts the risks, but may change their decision by contacting the doctor. The form requires signatures from the patient, a witness,

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brownboomerang
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354 views1 page

Refusal of Treatment Form

This document is a refusal of treatment form for a patient who has been recommended for a test, treatment, or procedure by their doctor. It includes spaces for the patient's name and contact information, as well as the recommending doctor's name. The form acknowledges that the patient has been informed of their medical condition, the purpose and nature of the recommended treatment, risks and benefits, alternatives, and that all their questions have been answered. It notes potential risks of refusing treatment, including delayed diagnosis and impaired health. Though refusing treatment could seriously harm their health or result in death, the patient chooses to refuse and accepts the risks, but may change their decision by contacting the doctor. The form requires signatures from the patient, a witness,

Uploaded by

brownboomerang
Copyright
© Attribution Non-Commercial (BY-NC)
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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REFUSAL OF TREATMENT FORM

______________________________
Patient Name

_______________________
Date of Birth

______________________________
Relationship to Patient

_______________________
Patient Phone number

Dr. ____________________ has recommended that I undergo the following test/ treatment/ procedure:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I acknowledge the following:
1. My medical condition has explained to me by my physician
2. The reason for and/or the purpose of the recommended test/ treatment/ procedure have been
explained to me
3. The nature of the recommended test/ treatment procedure has been explained to me
4. The risks and benefits of the recommended test/ treatment/ procedure have been explained to
me
5. The alternatives (including non-treatment) to the recommended test treatment/ procedure
have been explained to me
6. All of my questions about the recommended test/treatment/ procedure have been answered to
my satisfaction
The risks of refusing the recommended test/treatment/procedure have been explained to me. They
include, but are not limited to:
Potential delay in diagnosis and treatment of health conditions.
I also understand there could be risks of refusing the recommended test/treatment/procedure that are
not yet known. Although my refusal to follow Dr. _________________ advice and undergo the
recommended Test/treatment/procedure could seriously impair my health or even result to death, I
choose to refuse the recommended test/procedure/treatment and accept the risks and consequences
of my decision. I understand that I could change this decision at any time by contacting Dr. _________s
office and taking action to cancel this refusal.
______________________________________________________________________
Patient Name/ Representative
Date
______________________________________________________________________
Witness Signature
Date
______________________________________________________________________
Physician Signature
Date

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