Refusal to Permit Medical Treatment Form

I hereby acknowledge that my attending physician, ______________________________, has fully informed me of the risks, possible complications, expected benefits, and the alternatives to receiving the following medical treatment:

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Notwithstanding the recommendations of my attending physician, I hereby refuse the foregoing treatment for me or my child. I hereby release my physician, his or her personnel, and any other persons participating in my care from any responsibility whatsoever for unfavorable or untoward results, which I understand may occur as a result of my refusal to permit this medical treatment.

____________________________________________ Patient/Parent/Conservator/Guardian		________________ Date
____________________________________________ If signed by other than the patient, indicate relationship to the patient
____________________________________________ Witness Signature		________________ Date

The original goes into the patient’s medical record, and one copy goes to the patient for his or her records.