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AGAINST MEDICAL ADVICE AMA FORM This is to certify that I a patient at fill in name of your hospital am refusing at my own insistence and without the authority of and against the advice of my attending physician s request to leave against medical advice. The medical risks/benefits have been explained to me by a member of the medical staff and I understand those risks. I hereby release the medical center its administration personnel and my attending and/or resident physician s from any responsibility for all consequences which may result by my leaving under these circumstances. MEDICAL RISKS Death Additional pain and/or suffering Risks to unborn fetus Permanent disability/disfigurement Other MEDICAL BENEFITS History/physical examination further additional testing and treatment as indicated* Radiological imaging such as CAT scan X-rays ultrasound sonogram Laboratory testing Potentional admission and/or follow-up Medications as indicated for infection pain blood pressure etc* Please return at any time for further testing or treatment Patient Signature Date Physician Signature Witness. The medical risks/benefits have been explained to me by a member of the medical staff and I understand those risks. I hereby release the medical center its administration personnel and my attending and/or resident physician s from any responsibility for all consequences which may result by my leaving under these circumstances. I hereby release the medical center its administration personnel and my attending and/or resident physician s from any responsibility for all consequences which may result by my leaving under these circumstances. MEDICAL RISKS Death Additional pain and/or suffering Risks to unborn fetus Permanent disability/disfigurement Other MEDICAL BENEFITS History/physical examination further additional testing and treatment as indicated* Radiological imaging such as CAT scan X-rays ultrasound sonogram Laboratory testing Potentional admission and/or follow-up Medications as indicated for infection pain blood pressure etc* Please return at any time for further testing or treatment Patient Signature Date Physician Signature Witness. The medical risks/benefits have been explained to me by a member of the medical staff and I understand those risks. I hereby release the medical center its administration personnel and my attending and/or resident physician s from any responsibility for all consequences which may result by my leaving under these circumstances. MEDICAL RISKS Death Additional pain and/or suffering Risks to unborn fetus Permanent disability/disfigurement Other MEDICAL BENEFITS History/physical examination further additional testing and treatment as indicated* Radiological imaging such as CAT scan X-rays ultrasound sonogram Laboratory testing Potentional admission and/or follow-up Medications as indicated for infection pain blood pressure etc* Please return at any time for further testing or treatment Patient Signature Date Physician Signature Witness. .

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