REFUSAL OF TREATMENT
Patient (or Authorized Representative’s) Refusal of Medical Treatment
______________________________________________________________________________
Patient’s Printed Name
Date of Birth
I hereby certify my physician, Dr. [insert physician name], has informed me of the nature of the
following test, treatment, operation or procedure, which I am refusing:
[Describe test, treatment, operation or procedure]
My physician has informed me of the risks and complications that the above involves, as well as
the expected benefits and alternatives.
Specific, significant and probable risks of refusing my physician’s recommendations include, but
are not limited to, the following:
[Describe specific, significant and probable risks]
I understand the above list is not exhaustive and other complications of my refusal may result.
I also understand my refusal may seriously impair my health and well-being, as well as my
physician’s ability to appropriately treat me. This is my choice and I assume the risks and
consequences involved in my refusal, and I will not hold liable my physician nor any other
healthcare personnel or entity participating in my care.
If the signature below is of an authorized representative, the authorized representative is to
also complete and certify that the following is true: I am legally authorized to provide consent
on behalf of the patient listed above. My relationship to the patient is described as follows:
______________________________________________________________________________
Signature of Patient (or Authorized Representative)
Relationship to Patient
______________________________________________________________________________
Time
Date
______________________________________________________________________________
Signature of Witness [Preferably family member]
Relationship to Patient
______________________________________________________________________________
Signature of Authorized Representative
This is only a sample form. It must be revised to the situation and any appropriate state law.
Rev 3/15