Orris

Write a refusal for pt. Who refuse to take treatment

Here is a professional Patient Refusal of Treatment form/letter you can use or adapt:

REFUSAL OF TREATMENT FORM

Date: _______________ Time: _______________ Facility/Clinic Name: _______________

PATIENT INFORMATION

Patient Name: _______________ Date of Birth: _______________ Medical Record No.: _______________

STATEMENT OF REFUSAL

I, _______________________ (patient name), hereby voluntarily refuse the following recommended treatment, procedure, or medication:
Treatment/Procedure Refused:
Recommended by (Provider Name):

INFORMED REFUSAL ACKNOWLEDGMENT

I confirm and acknowledge that:
  1. My healthcare provider has explained the nature of my condition and the recommended treatment.
  2. I have been informed of the risks and potential complications of refusing this treatment, which may include (but are not limited to):
    • Worsening of my current condition
    • Permanent disability or damage
    • Death or life-threatening consequences
  3. I have been offered alternative treatments, if any, and have been given the opportunity to ask questions.
  4. I understand my right to seek a second opinion or return for care at any time.
  5. I am making this decision of my own free will, without coercion or undue influence.
  6. I am of sound mind and competent to make this decision.

REASON FOR REFUSAL (optional)

SIGNATURES

Patient SignatureDate / Time
__________________________________________
Witness Name (Print)Witness Signature
______________________________________________________
Provider Name (Print)Provider Signature
______________________________________________________

PROVIDER DOCUMENTATION NOTE

To be completed by the treating provider:
The patient was informed of their diagnosis, the proposed treatment plan, and the risks of refusal. The patient demonstrated understanding and refused voluntarily. The patient was advised they may return for treatment at any time.
Provider Notes:
Note: This signed form should be placed in the patient's medical record. If the patient refuses to sign, document that refusal in the chart and have a witness co-sign.
Let me know if you need this tailored for a specific specialty (e.g., surgery, psychiatry, medication refusal, or discharge against medical advice - AMA).
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