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Get Form Release Against Advice 2004-2024

ITY UPON LEAVING HOSPITAL/CLINIC AGAINST MEDICAL ADVICE 1. This is to certify that I am leaving at my own insistence and against the advice of the (Name of Medical Treatment Facility) hospital/clinic authorities and my attending physician(s). 2. I have been advised of and understand the potential dangers involved in leaving the hospital/clinic at this time. The potential medical risks that have been explained to me include: 3. I have been advised of and understand the follow-up actions recomm.

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