Against Medical Advice (Ama Form)
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This is to certify that I, ________________________________________,
a patient at __________________________________________(fill in name
of your hospital), am refusing at my own insistence and without the authority
of and against the advice of my attending physician(s)
_______________________________________, request to leave against
medical advice.
The medical risks/benefits have been explained to me by a member of the
medical staff and I understand those risks.
I hereby release the medical center, its administration, personnel, and my
attending and/or resident physician(s) from any responsibility for all
consequences, which may result by my leaving under these circumstances.

_____Additional pain and/or suffering

_____Risks to unborn fetus

_____Permanent disability/disfigurement