LAMA Medical Discharge Consent Form
Please review and complete this form to acknowledge your decision to be discharged against medical advice. This form documents your understanding of the risks and your consent to proceed with discharge.
Patient Full Name
*
First Name
Last Name
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Attending Physician
*
First Name
Last Name
Reason for Choosing Discharge Against Medical Advice (optional)
Patient Signature
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Witness / Staff Name
*
First Name
Last Name
Witness / Staff Signature
*
Submit Consent
Submit Consent
Should be Empty: