Understanding the Against Medical Advice (AMA Form) is critical for patients considering leaving the hospital under circumstances not recommended by their healthcare team. This form plays a pivotal role in such situations, documenting a patient's decision to leave the healthcare facility despite the attending physician's advice to the contrary. By completing this form, patients acknowledge they are departing against medical recommendations and fully understand the potential risks and benefits associated with their decision. Risks outlined may include death, additional pain or suffering, risks to an unborn fetus, permanent disability or disfigurement, alongside other possible consequences. On the flip side, the form also lists medical benefits that could be forfeited by leaving, such as diagnostic tests, further treatment, radiological imaging, or laboratory testing. Completion of this form signifies a patient's informed consent, releasing the medical center and its staff from liability for any consequences that may result from this action. With a patient's signature, the AMA form underscores the gravity of leaving care early and ensures that all parties are aware of the implications. It acts as a critical legal document within healthcare settings, providing a clear record of the patient's understanding and acceptance of the risks associated with their choice.
| Question | Answer |
|---|---|
| Form Name | AMA Form |
| Form Length | 1 pages |
| Fillable? | Yes |
| Fillable fields | 27 |
| Avg. time to fill out | 5 min 39 sec |
| Other names | release against medical advice, leave against medical advice form, ama form veterinary, veterinary ama form |
AGAI N ST M ED I CAL AD V I CE ( AM A FORM )
This is t o cer t ify t hat I , ________________________________________ ,
a pat ient at __________________________________________ ( fill in nam e
of y our hospit al) , am r efusing at m y ow n insist ence and w it hout t he aut hor it y of and against t he adv ice of m y at t ending phy sician( s)
_______________________________________ , r equest t o leav e against
m edical adv ice.
The m edical r isk s/ benefit s hav e been ex plained t o m e by a m em ber of t he m edical st aff and I under st and t hose r isk s.
Iher eby r elease t he m edical cent er , it s adm inist r at ion, per sonnel, and m y at t ending and/ or r esident phy sician( s) fr om any r esponsibilit y for all consequences, w hich m ay r esult by m y leav ing under t hese cir cum st ances.
MEDI CAL RI SKS |
|
_____ Deat h |
_____ Addit ional pain and/ or suffer ing |
_____ Risk s t o unbor n fet us |
_____ Per m anent disabilit y / disfigur em ent |
_____ Ot her : ___________________________________________________
_____________________________________________________________
_____________________________________________________________
MEDI CAL BENEFI TS
_____ Hist or y / phy sical ex am inat ion, fur t her addit ional t est ing and t r eat m ent
as indicat ed.
_____ Radiological im aging such as:
_____ CAT scan ____ X- r ay s ____ ult r asound ( sonogr am )
_____ Labor at or y t est ing _____ Pot ent ional adm ission and/ or follow - up
_____ Medicat ions as indicat ed for infect ion, pain, blood pr essur e, et c.
_____ Ot her : ____________________________________________
Please r et ur n at any t im e for fur t her t est ing or t r eat m ent
Pat ient Signat ur e_______________________ |
Dat e_______________ |
Phy sician Signat ur e_____________________ |
Dat e_______________ |
Wit ness ______________________________ |
Dat e_______________ |