Patient Refusal Survey
Please complete this form to document your decision to refuse a recommended treatment or procedure. Your responses help us understand your perspective and ensure you are fully informed of the associated risks.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Refusal
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What type of treatment, procedure, or medical advice are you refusing?
*
Please Select
Medication
Surgery
Diagnostic Test
Hospital Admission
Vaccination
Other
Please indicate your primary reason(s) for refusal:
*
Concerns about side effects or risks
Prefer alternative treatments
Personal or religious beliefs
Financial reasons
Lack of trust in recommendation
Other
How well do you feel you understood the information provided about the recommended treatment or procedure?
*
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
Please rate the clarity of the explanation you received from your healthcare provider.
*
1
2
3
4
5
Have you discussed your decision with your healthcare provider?
*
Yes
No
Please provide any additional comments or concerns regarding your decision to refuse the recommended treatment or procedure.
Patient Signature
*
Submit
Submit
Should be Empty: