LOGO DE PHGI

REFUSAL OF MEDICAL TREATMENT FORM I. Treatment and/or Procedure: My physician advised me and considers that I should undergo the following treatment(s) and/or procedure(s) in this facility: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________. II. Necessary Information to Refuse Treatment(s) and/or Procedure(s): My physician explained to me and I understood the following: A. B. C. D. E. The nature of the treatment(s) and/or procedure(s) recommended. The purpose and necessity of the treatment(s) and/or procedure(s) recommended. The risks and benefits of the treatment(s) and/or procedure(s) recommended. The existing alternatives to treat my condition(s). The possible consequences of not continuing with the treatment(s) and/or procedure(s) recommended.

III. Patients Refusal: I recognize that my refusal to follow the recommendations above mentioned, will put in risk my life or health. Nevertheless, I refuse the treatment(s) and/or procedure(s) recommended. I assume the risks and consequences of my refusal to receive the treatment(s) and/or procedure(s) above indicated and release of responsibility Professional Hospital Guaynabo, Inc. and its employees, as well as my physician(s) of any responsibility for the conditions, complications and/or injuries caused by my refusal to follow the medical recommendations. IV. Final Acknowledgement: My signature in this form represents the following: A. Everything expressed before is correct and true; B. I read or was read to and understood the information provided in this form; C. I reaffirm everything I have recognized and accepted in this form and I do it voluntarily; D. I recognize that in the event in which any clause or part of this form is declared illegal or null by a Court, said declaration will not lessen the other clauses and its effect will be limited to the declared illegal or null clause. AND TO CONFIRM, I SIGN THIS FORM. I sign this document on my behalf. In the event that the patient is a minor or incapable to consent, my signature represents that I am the person entrusted and I have legal capacity to authorize and consent to what is expressed in this document in the name of the patient.

INITIALS: ______

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Patients Name: ___________________________________ Patients Signature:________________________________________

Date: ___/___/____
(month/day/year)

Time: ________ AM/PM

If the patient cannot sign due to age minority or is physically or mentally impaired, please fill out the following information.
Patients reason for not signing: [ ] Minority [ ] Impairment to consent [ ] Temporary [ ] Permanent Representative(s) Name(s): ______________________________________________ ______________________________________________ Representative(s) ID #: ___________________________ Representative(s) Signature(s): Signature: _____________________________________________ Signature: _____________________________________________ Physicians Name:_________________________________________________ Signature: ______________________________________________ Date: ___/___/____
(month/day/year)

Representative(s) relation with the patient: [ ] Father [ ] Mother [ ] Son or Daughter [ ] Spouse [ ] Other: Explain: __________________________

Time: ________ AM/PM Date: ___/___/____

(month/day/year)

Time: ________ AM/PM

IMPORTANT NOTE: In the case of impairment due to minority, the consent of both parents (father and mother) is required, except in the case of an emergency certified by the physician. Every person that signs in representation of a patient must provide valid identification to be photocopied and attached to the consent form.

Rev. 05/2009

INITIALS: ______

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