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Against Medical Advice Template 2 -Form Fill
Q1
First Name
Patient's Name:
Q2
Last Name
Patient's Name:
Q3
First Name
Physician's Name:
Q4
Last Name
Physician's Name:
Q5
Physician's Medical Advice:
Q6
Medical Risks:
Death
Additional pain and/or suffering
Permanent disability/disfigurement
Other
Q7
Medical Benefits:
Q9
Patient's Signature:
Q10
Physician's Signature:
Q11
First Name
Witness Name:
Q12
Last Name
Witness Name:
Q13
Witness Signature:
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