AGAINST MEDICAL ADVICE (AMA FORM) at a glance
What it is: This form is for a patient who certifies they are refusing, at their own insistence and without the authority of and against the advice of the attending physician(s), and request to leave against medical advice.
Who signs: Patient Signature and Date, Physician Signature and Date, and Witness and Date each get a signature and a date.
A filled-in AGAINST MEDICAL ADVICE (AMA FORM) example: a patient leaves against medical advice
How to fill out AGAINST MEDICAL ADVICE (AMA FORM), box by box
Patient, hospital and attending physician
Write your name after This is to certify that I, the name of your hospital after a patient at, and the attending physician(s) after of and against the advice of my attending physician(s); the patient is refusing without the authority of the attending physician(s).
Medical risks
Under MEDICAL RISKS, mark Death, Additional pain and/or suffering, Risks to unborn fetus or Permanent disability/disfigurement, and write any other risk after Other; the patient is leaving without the authority of the physician(s).
Medical benefits
Under MEDICAL BENEFITS, mark History/physical examination, further additional testing and treatment as indicated; Radiological imaging such as CAT scan, X-rays or ultrasound (sonogram); Laboratory testing; Potentional admission and/or follow-up; Medications as indicated for infection, pain, blood pressure, etc.; or Other.
Signatures and dates
Patient Signature and Date, Physician Signature and Date, and Witness and Date each get a signature and a date.
More rules for AGAINST MEDICAL ADVICE (AMA FORM)
Please return at any time for further testing or treatment.
Sources
[1] AGAINST MEDICAL ADVICE (AMA FORM) (the served file; no issuer file found) (the Official source link on this page).