Hospital Discharge Liability Waiver Form
Please complete this form to acknowledge and accept the terms of discharge from the hospital.
Patient Full Name
*
First Name
Last Name
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email Address
*
example@example.com
Acknowledgment of Discharge
*
I acknowledge that I am being discharged from the hospital and understand the implications.
Reason for Discharge
*
Please Select
Discharged by physician
Discharged at own request
Transferred to another facility
Other
Waiver of Hospital Liability
*
I understand and accept that the hospital is not liable for any outcomes following my discharge.
Statement of Understanding
*
I confirm that I have read and fully understand the terms outlined in this Hospital Discharge Liability Waiver Form.
Signature of Patient or Authorized Representative
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Waiver
Submit Waiver
Should be Empty: