Sample Informed Refusal printable pdf download

Sample informed refusal

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In order to diagnose/treat my condition a _____________________________________________ was ordered

for me on ______________________________________. The reasons for ordering this test/procedure have

been carefully explained to me. I understand the potential benefits are:

_____________________________________________________________________________________________

and the alternatives include ____________________________________________________________________

_____________________________________________________________________________________________.

In addition, Dr. ___________________________________ has informed me of the risks involved in not

having a _____________________________________________________ performed. These risks include

_____________________________________________________________________________________________

_____________________________________________________________________________________________.

After careful consideration of the potential benefits and risks concerning the above, I am refusing

______________________________________________________________. My reason(s) for refusing is (are):

_____________________________________________________________________________________________

_____________________________________________________________________________________________.

___________________________________________

________________________________________

Patient signature

Witness signature

___________________________________________

________________________________________

Date

All articles and any forms, checklists, guidelines and materials are for generalized information only, and should not be reviewed or

referred to as primary legal sources nor construed as establishing medical standards of care for the purposes of litigation, including expert

testimony. They are intended as resources to be selectively used and always adapted – with the advice of the organization’s attorney – to

meet state, local, individual organizations and department needs or requirements. They are distributed with the understanding that nei-

ther Texas Medical Liability Trust nor Texas Medical Insurance Company is engaged in rendering legal services.

Sample Informed Refusal