Airport Animal Emergi-Center Against Medical Advice (Ama Form) Release printable pdf download

Airport Animal Emergi-Center Against Medical Advice (Ama Form) Release

Against Medical Advice (AMA form) Release

This is to certify that I, _____________________________, owner or agent of the owner of the

above identified animal, choose to refuse further diagnostics/treatments/hospitalization for this

animal that is recommended by the medical staff of the Airport Animal Emergi-Center, P.C.

A member of the staff has explained the medical risks/benefits to me and I understand those risks

to include death. I have been advised other unknown complications/risks are also possible.

Being aware of this it is still my desire to refuse the advised medical care.

I hereby release the Airport Animal Emergi-Center, P.C.; it’s doctors and staff from any liability

or medical claims resulting from my refusal of medical care.

I hereby request that my animal be released to me in spite of its medical condition and I fully

recognize that this release is against the doctor’s recommendations.

__________________________________

_______________

Signature of Owner or Agent of Owner

Date

__________________________________

________________

Signature of Witness

Date

=====================================================================

Refusal to Sign Release Form

On ___________________, _____________________________________________did:

Date

Owner or Agent of Owner

______ Refuse advised medical care.

______ Refuse to sign the above Release Form

____________________________________

___________________________________

First Witness

Second Witness

Airport Animal Emergi-Center Against Medical Advice (Ama Form) Release