Discharge Against Medical Advice

Discharge Against Medical Advice

MR No. : __________________________________________ IPD No ________________________________

Patient Name: ______________________________________ DOA _________________________________

I, Mr. / Ms. ___________________________________ Son / Daughter / Wife of ________________________ take the full responsibility in having Mr. / Ms. ____________________________________________________ to ______________________________________________________________________________________ Son / daughter / Wife of _____________________________________________________________________ discharged against medical advice at his / her own risk.

The condition of the patient and the consequence have been explained to me and no one (not even the patient) will ever hold ____________Hospital or its staff in any way responsible for any out come whatsoever.

Date :                                                                                       Time :

Duty Doctor’s Name :                                                             Signature :

Duty Nurse’s Name :                                                               Signature :

Patient Name                                                                            Signature :

Attendant Name                                                                        Relationship :

Signature