Form Ama is an ancient Egyptian form of therapeutic massage. It is said to be the oldest form of massage still in use today. While its exact origins are unknown, it is thought to have developed out of a combination of yoga and Ayurvedic medicine. Ama Form is based on the belief that energy flows through the body in specific channels, or meridians. By manipulations of the muscles and tissues along these channels, blocked energy can be released, restoring balance and health to the body. Ama Form is particularly beneficial for chronic pain, stress, and other health concerns. If you're looking for an alternative to traditional massage or want to try something new, give Ama Form a shot!
| Question | Answer |
|---|---|
| Form Name | Ama Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | medical advice form, veterinary ama form, against medical group, release against medical advice |
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_______________ |