Release of Physician Hospital If Treatment Not Completed
Release executed by ___________ (name), of ______________ (address), as releasor, to ___________ (hospital), located at _______________ (address), its directors, medical and surgical staff, agents, employees and any other person connected therewith, and to ____________________________________ (name of physician), whose office address is __________ (address).
I, _________ (name), was admitted by ___________ (physician) as a patient in _________ (name of hospital) on _____ (date). I have requested discharge and removal from the hospital against the advice of ___________ (name of physician). I hereby release the hospital, its directors, medical and surgical staff, agents, employees and other persons connected therewith, and ________________________________ (name of physician), severally and individually, from any and all liability of any nature for whatever injury or harm or complication of any kind that may result, whether directly or indirectly, by reason of the discharge, if granted. I hereby waive any and all rights of action I may now have or later acquire as a result of such discharge and removal. I understand that based on my complaint of ____________. (describe), prevailing medical opinion, as explained to me by _____________ (name of physician), requires the following treatment: ___________ (explain). However, after having such treatment fully explained to me by my physician, as well as the possible consequences of such treatment, and the possible consequences of my failure to undergo such treatment, and against the advice of my physician, ______________ (name of physician), I have decided not to undergo such treatment.
_______ (Name of physician) has explained to me in detail the medical complications, including, but not limited to, ______________(enumerate) and possible results of such complications, such as __________ (enumerate), as a result of my action. This release is made with full knowledge of the danger that may result from my discharge and removal from _______________________________ (name of hospital).
In witness whereof, releasor executes this release at ____________ (designate place of execution) on ____ (date)
Executed in the presence of:
(Signatures of witnesses, with names and addresses indicated for each person)