Informed Refusal Form

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First Name *

Last Name *

Date of birth *

YYYY

My physician, Dr. Arun Villivalam, has recommended the following test / procedure / treatment: *

He has explained to me that the potential benefits of the test /procedure / treatment include: *

and that the risks are: *

Despite my physician's recommendation, I refuse to consent to this medical treatment. The physician has explained the following risk to my refusal. They include, but are not limited to: *

By typing my full name in the box below, I acknowledge that my medical condition has been evaluated and explained by my physician, who has recommended treatment as stated above, and that the doctor has explained to me the potential benefits of such treatment and the risks associated with it, as well as the probable risks of not following the recommended treatment, which I fully understand. In spite of this understanding, I refuse to consent to this medical treatment. Signature of patient or authorized individual: *

The patient/authorized individual has read this form or had it read to him or her.
The patient/authorized individual states that he or she understands this information.
The patient/Authorized individual has no further questions.

Signature of witness:

If signed by someone other than patient, indicate relationship and your full name.

Signature of witness

Today's date

YYYY

Time

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