I have been advised by Dr. ____________ that the following treatment, _________________________, should be given to me or the named patient (if a minor):_________________________

Dr. ____________ has fully explained to me the nature, purpose, risks, and benefits of the proposed treatment, the possible alternatives thereto, and the risks and consequences of not proceeding. I nonetheless refuse to consent to the proposed treatment.

I have been given an opportunity to ask questions, and all of my questions have been answered fully and satisfactorily.

I hereby release the hospital, its employees and medical staff, medical students, and the attending physician from any liability for ill effects that may result from my decision to refuse to consent to the proposed treatment.

I confirm that I have read and fully understand the above and that all the blank spaces were completed prior to my signing.

Patient/Relative or Guardian* ___________________________
Signature, Print name, Date

Relationship (if signed by person other than patient):

Interpreter (if used): __________________________________
Signature, Print name, Date

*The signature of the patient must be obtained unless the patient is a minor or is otherwise incompetent to sign.

Witness: ____________________________________
Signature, Print name, Date

Physician Certification

I hereby certify that I have explained the nature and purposes of, and alternatives to, the proposed treatment mentioned above, and the risks and consequences of not proceeding. I have offered to answer any questions and have fully answered all such questions. I believe that the patient/relative/guardian fully understands what I have explained and answered.

Physician: _________________________________________
Signature, Print name, Date