Hospitals & healthcare
Discharge against medical advice template
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Discharge Against Medical Advice
Date and time: Date – Time
I, Patient Name, file no. File Number, wish to leave the hospital before my treatment is complete and against medical advice. Dr. Physician Name has explained the possible risks, which are Risks Explained, and I accept full responsibility.
Patient: Patient Signature
Physician: Physician Signature
Witness: Witness Signature