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> refusal of treatment letter
refusal of treatment letter
1. Patient Information
Name of the patient
Date of birth
Contact information
Patient ID or medical record number
2. Treatment Details
Description of the proposed treatment
Purpose of the treatment
Risks associated with the treatment
Benefits of the treatment
3. Refusal Statement
Clear statement of refusal of treatment
Date of refusal
Reason for refusal (if applicable)
4. Understanding of Consequences
Acknowledge understanding of potential risks of refusing treatment
Confirm understanding of alternative treatment options
Document that the patient understands the consequences of refusal
5. Signature Section
Space for patient’s signature
Date of signature
Space for witness signature (if applicable)
Date of witness signature (if applicable)
6. Additional Information
Provide information on how to contact healthcare provider for questions
Include a statement encouraging the patient to reconsider their decision
Offer resources or referrals for further consultation if needed
7. Documentation
Ensure a copy of the refusal letter is placed in the patient's medical record
Note in the medical record that the patient refused treatment and the details of the refusal
8. Follow-Up
Schedule a follow-up appointment to discuss the refusal and any ongoing concerns
Document any follow-up actions taken in the medical record
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