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I personally assume the risks and consequences of my refusal, and release for myself, my heirs, executors, administrators or personal representatives those physicians/providers who have been consulted in my case as well as (insert name of medical practice) , its officers, agents and employees, from any and all
consult with the patient/client and (if appropriate) their family. make an accurate record of the decision to refuse to treat, to include the reasons for the decision so that you are able to justify your actions later if care is withdrawn.
Most people in the United States have a right to refuse care if treatment is for a non-life-threatening illness. This may include not getting a prescription filled, not getting a flu shot, or deciding to stop using crutches after you sprained an ankle.
If a customer is causing a scene by yelling, swearing, or making a mess, or theyre clearly intoxicated, you have a right to refuse them. When a customer breaks the rules of your establishment, which are within local, state and federal statutes, you are under no obligation to serve them.
The right to refuse medical treatment is generally based on the common law right of self-determination of ones body, the ethical principle of respect for autonomy,1 and the doctrine of informed consent.

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The documentation should include when and where the discussions occurred; who participated or was physically present during the conversations; the options, risks, benefits, costs, and possible outcomes addressed; and notations that the patients questions were answered.
Patients may refuse treatments for many reasons, including financial concerns, fear, misinformation, and personal values and beliefs. Exploring these reasons with the patient may reveal a solution or a different approach.

printable refusal of medical treatment form