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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:
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:
*** If Required By State Law ***
This Section for Notary:
STATE OF -------)
) ss: [date]
COUNTY OF ------)
On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal.
[Name of Notary Public]
My commission expires: [date]