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Against Medical Advice Form Template

Streamline Patient Discharges with the Right Forms

Leaving a medical facility against advice can be stressful for patients and providers alike. This Against Medical Advice (AMA) form template helps healthcare professionals secure documented consent, ensuring clarity and compliance. With this template, you'll simplify the discharge process, protect your legal interests, and enhance communication with patients, all while maintaining a clear record of their wishes. Designed with WCAG-aligned labels, it's easy to customize for your needs. Explore how you can start using this live template.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Medical record number (MRN)
Primary phone number
Email (optional)
Primary language
Interpreter language (if applicable)
Interpreter needed
Yes
No
Facility name
Date of visit
Attending clinician full name
Reason for visit / primary concern
Recommended tests and treatments
Specific tests or treatments the patient is declining
Condition at time of departure
Stable
Improved
Unchanged
Worsened
Unknown
Intended time of departure (HH:MM)
Accompanied by (name and relationship, if applicable)
Mode of departure
Self (driving)
Self (walking)
Picked up by family or friend
Rideshare or taxi
Public transport
Medical transport arranged by facility
Other
Please Specify:
I have been informed of my current condition and the care recommended to me.
Yes
No
I was informed of the benefits of the recommended care and the risks of not receiving it.
Yes
No
I had the opportunity to ask questions and received answers I could understand.
Yes
No
I understand that leaving now may increase risks, including worsening illness, permanent disability, or death.
Yes
No
I understand I may return for care at any time or call emergency services if my condition worsens.
Yes
No
I accept responsibility for my decision to leave at this time.
Yes
No
Primary reason for leaving
Feeling improved
Wait time
Financial or insurance concerns
Prefer to seek care elsewhere
Family or personal obligation
Dissatisfied with care
Environment or comfort
Transportation issue
Other
Please Specify:
If 'Other', please specify reason
If driving self, I understand I should not drive if impaired by illness, injury, or medication.
Yes
No
Care options offered (select all that apply)
Observation period offered
Alternative treatments offered
Transfer to another facility offered
Follow-up appointment offered
Social work or case management offered
Pain or symptom control offered
Interpreter offered
Security or chaperone offered
Other
Please Specify:
Prescriptions provided
Yes
No
Written discharge instructions provided and reviewed
Yes
No
Warning signs and when to seek urgent care explained
Yes
No
Follow-up provider or clinic (name)
Follow-up date (if scheduled)
Transportation arranged by facility
Yes
No
Special instructions or restrictions
Personal belongings and valuables returned
Yes
No
Emergency contact full name
Emergency contact phone
Relationship to patient
Patient declined or unable to sign
Yes
No
Patient or authorized representative full name
Reason representative is signing (if not the patient)
Patient or authorized representative signature
Date of patient/representative signature
Witness full name
Witness signature
Date of witness signature
Clinician full name
Clinician credentials or title
Clinician signature
Date of clinician signature
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Paper art illustration depicting an against medical advice form for FormCreatorAI article.

When to use this form

Use this form when an adult patient chooses to leave a hospital, ED, clinic, or telehealth visit before recommended evaluation or treatment. It helps you document informed refusal, decision-making capacity, risks discussed, and return precautions. Staff also use it when a parent declines care for a minor or a caregiver refuses a recommended vaccine; pair it with a Covid-19 vaccine declination form. If the patient asks you to share updates with a family member or facility, include a HIPAA Authorization form. For virtual visits, confirm a Telehealth consent form is on file. With clear signatures, witness notes, and follow-up contacts, you reduce liability, set expectations, and give the patient a safe path back to care.

Must Ask Against Medical Advice Questions

  1. What diagnosis, recommended treatment, and risks do you understand and accept by leaving now?

    This confirms informed refusal and documents that you explained material risks in plain language. It protects your team by showing the patient understood potential outcomes.

  2. What are your main reasons for refusing treatment or requesting discharge today?

    Knowing the why helps you tailor counseling, offer alternatives, or remove barriers. It also records nonmedical factors (work, childcare, cost) that shape the decision.

  3. Do you have a safe plan for follow-up care, transportation, and a place to recover?

    This checks immediate safety and continuity of care. It lets you provide written instructions, phone numbers, and a clear return pathway.

  4. Do costs or insurance coverage affect your decision, and may we discuss this with your insurer?

    Financial stress often drives early departure; asking can surface solvable issues. With permission, you can use the Medicare consent release form to clarify coverage or options.

  5. What instructions, return precautions, and alternatives to leaving will you follow?

    This ensures the patient knows warning signs and safer options. It creates a clear record of next steps and who to contact if symptoms worsen.

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