Pregnancy Waiver Form

Pregnancy Waiver Form
Patient name
First NameLast Name
Date of birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How did you certify your non-pregnancy?
Pregnancy test date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical certificate from your doctor
Cancelof
I certify that I am not pregnant and that I fully understand and have been informed of all risks while pregnant, including surgery, radiation and anesthesia. If there was a chance of pregnancy, I was offered the opportunity to take a pregnancy test. I also knowledge and understand the pregnancy test may show a false result and are not 100% accurate. If I am really pregnant at the time of surgery and anesthesia, I release the hospital/clinic from any liability.
Patient signature
Clear
Should be Empty: