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