My physician has satisfactorily explained the above test(s). treatment(s). operation (s) or procedure(s) to me, the risks and benefits
of this recommendation, the alternatives to this recommendation and the probable consequences of not undergoing the test(s). treatment(s),
operation (s) or procedure(s). In addition,
I have had the opportunity to ask questions about the proposed recommendation and have had these answered to my satisfaction.
Notwithstanding the recommendation of my physician and with the knowledge I have regarding this recommendation. I have decided NOT
to accept/permit the test(s), treatment(s). operation (s) or procedure(s) listed above. I understand that
my failure to follow my physician's advice may seriously affect my health (or the health of the person under my guardianship)
By signing below. I assume responsibility for all the risks and consequences of my refusal. I also release the , Dr. and other persons participating in my care (or that of the person under my guardianship) from all responsibility for any unfavorable or adverse outcomes that may occur as a result of my refusal to accept/permit the proposed recommendation.
I confirm that I have read and fully understood the above consent before signing it.