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Against Medical Advice Template 1 -Form Fill

Section One
Q1

Patient's Name:

First Name
Q2

Patient's Name:

Last Name
Q3

Physician's Name:

First Name
Q4

Physician's Name:

Last Name
Q5

Physician's Medical Advice:
Q6

Medical Risks:
Q7

Medical Benefits:
Q8

Today's Date:

Date
Q9

Patient's Signature:
Q10

Physician's Signature:
Q11

Witness Name:

First Name
Q12

Witness Name:

Last Name
Q13

Witness Signature: