Hospitals & healthcare
Refusal of treatment template
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Preview — Formal concise
Refusal of Treatment
Date and time: Date – Time
I, Patient Name, file no. File Number, refuse Refused Treatment recommended by Dr. Physician Name, after the risks of refusing were explained to me, namely Risks Explained. I take full responsibility for my decision.
Patient: Patient Signature
Physician: Physician Signature
Witness: Witness Signature