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INFORMED REFUSAL OF TREATMENT
I have been informed by
of my condition and the recommended treatment consisting of:
I have also been offered alternative treatments which include:
After considering all treatment possibilities with
and having the risks and benefits of each explained to my satisfaction, I have voluntarily chosen and having the risks and benefits of each explained to my satisfaction, I have voluntarily chose to:
I understand that my decision is contrary to the recommended course of treatment and that my condition may significantly worsen as a result, and/or require additional therapy and/or hospitalization, or in rare circumstances, may be life threatening. I AGREE TO RETURN FOR PERIODIC MONITORING AS SCHEDULED BY
AND UNDERSTAND THAT I MAY RECONSIDER MY DECISION AT ANY TIME.
Patient's (or Legal Guardian's) Signature
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Doctor's Signature
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Witness' signature
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First Name
Last Name
Date Of Birth
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