U N I V ER SI T Y OF V I RGI N I A HE A LT H SYST E M 0100000 PLACE LABEL HERE - virginia 2026

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  2. Begin by filling in the patient name and medical record number in the designated area if the label is not available.
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  4. For each selected option, provide detailed information about the treatment refused, risks associated with refusal, benefits of examination/treatment, and reasons for refusal as prompted.
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