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AMA Form PDF

This document is an Against Medical Advice (AMA) form for a patient refusing treatment at a hospital against their doctor's advice. It certifies that the patient understands the medical risks explained to them by hospital staff but is insisting on leaving, and releases the hospital and doctors from any responsibility for consequences of leaving. The form lists potential medical risks like death, pain, disability, or risks to an unborn fetus, and benefits the patient is foregoing like examinations, tests, imaging, treatment, admission or follow-up care by refusing treatment. It requires signatures from the patient, physician and witness.

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1K views1 page

AMA Form PDF

This document is an Against Medical Advice (AMA) form for a patient refusing treatment at a hospital against their doctor's advice. It certifies that the patient understands the medical risks explained to them by hospital staff but is insisting on leaving, and releases the hospital and doctors from any responsibility for consequences of leaving. The form lists potential medical risks like death, pain, disability, or risks to an unborn fetus, and benefits the patient is foregoing like examinations, tests, imaging, treatment, admission or follow-up care by refusing treatment. It requires signatures from the patient, physician and witness.

Uploaded by

B P
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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