Informed Refusal Form printable pdf download

INFORMED REFUSAL

Consent is a process. It is the communication between a patient and a physician in which each party

asks questions and exchanges information, resulting in both the patient and the physician agreeing to

specific medical, surgical, pharmaceutical, or diagnostic interventions.

It is the obligation of the physician to provide you, the patient, with the information and advice needed

to make your healthcare choices. Ultimately, however, the decision for your healthcare rests with you.

This form will serve to acknowledge your refusal of the interventions and treatments prescribed by your

physician.

I, ______________________________ acknowledge that:

1. Dr. _______________________ has recommended ____________________________________

_______________________________________________________________________________

2. The recommendation has been made to me for the purpose of

_______________________________________________________________________________

3. I have decided to refuse the recommendation.

______ (initials)

4. My decision has been made after considering both the prescribed treatment as well as any other

alternative forms of treatment or diagnostic study for my condition. I fully understand that each of

the alternative forms of treatment/diagnostic study has its own potential benefits, risks, and

complications.

______ (initials)

5. I completely understand that there are possible risks, complications, and side effects involved in

refusing medical treatment. I also understand that it is impossible to list every risk, complication,

and/or side effect involved in my refusal, however I have been educated to some of them. They

could include, but not be limited to, the following:

_______________________________________________________________________________

Although these risks, complications and side effects may be rare, they do sometimes occur and

cannot be predicted or prevented by the health care provider. I acknowledge that no guarantee has

been made to me about the results of refusing the prescribed treatment/diagnostic study.

______ (initials)

6. I am aware that the potential risks and complications can result in additional medical or surgical

treatment, prolonged hospitalization or even permanent disability, severe injuries or death.

______ (initials)

7. I certify that I have read (or had read to me) the entire contents of this form. I acknowledge that the

possible risks and consequences created by my refusal to permit the recommended treatment have

been fully explained to me. I understand the possible benefits for allowing the recommended

treatment and the possible risks and consequences to myself because of my refusal for same.

__________________________________________________________________________________

Patient Signature

__________________________________________________________________________________

Witness

__________________________________________________________________________________

Date

Informed Refusal Form