Discharge Against Medical Advice (DAMA) Form

Discharge Against Medical Advice (DAMA) Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient Number
This is to certify that as a patient at Halimatu Musa Hospital, I am refusing at my own insistence and without the authority of and against the advice of my attending medical officers/physician(s), request to leave against medical advice.

The medical risks/benefits have been explained to me by a member of the medical staff and I understand those risks.

I hereby release the hospital, its administration, personnel, and my attending and/or resident medical officers/physician(s) from any responsibility for all consequences, which may result from my leaving under these circumstances.
MEDICAL RISKS INCLUDE THE FOLLOWING

DeathAdditional pain and/or sufferingRisks to unborn fetusPermanent disability/disfigurementOther
Other (please specify)
MEDICAL BENEFITS INCLUDE THE FOLLOWING:

Physical ExaminationFurther additional testing and treatment as indicatedMedical Imaging services such as: CT Scan, X-Ray, UltrasoundLaboratory TestingPotential admission and/or follow upMedications as indicated for infection, pain, blood pressure etcMinor or major surgery as indicatedOther
Other (please specify)
Patient Signature
Name

First NameLast Name
Date

MonthDayYear
Date
Medical Officer/Physician Signature
Name

First NameLast Name
Date

MonthDayYear
Date
Witness Signature
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty: