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Get and Sign Sample Urgent Care Against Medical Advice Form Ucaoa

Get and Sign Against Medical Advice Form

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S this facility against medical advice. Medical Risks Acknowledged Death Additional Pain and/or Suffering Permanent Disability and/or Disfigurement Other Describe Patient Declines Transport I acknowledge that I have a medical problem which requires additional medical attention and that an ambulance is/can be available to transport me to the hospital. Instead I elect to seek alternative medical care and refuse treatment and/or transport. Signature of Patient/Parent/Legal Guardian Date Time...
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