Against Medical Advice (AMA) Form

Informed decline of recommended care

01

Client & patient

02

What was recommended

Client’s decision
03

Acknowledgments

Please initial each statement
  1. The recommendation and the reasons for it were explained to me in language I understood.
  2. I understand the risks of declining, including those written above, which may include my pet’s condition worsening or death.
  3. I was able to ask questions, and I may change my decision and return for care at any time.
  4. I am the owner or authorized agent and I accept responsibility for this decision.
Client / authorized agent signature
Veterinarian signature
Witness signature