AMA Form - Prana IV Therapy

Against Medical Advice Form

Date*
MM slash DD slash YYYY
Patient Name*
First Last
Provider Name*
First Last
Recommendation:*
The above named provider has recommended a specific course of therapy, method of treatment or a means diagnosing and/or treating a medical condition for the patient named above. This decision is a medical decision that is made by the provider in consultation with the company medical director, based upon the findings of an examination and/or diagnostic testing. The provider believes this recommendation is in the patient’s best interest.

The specific recommendation(s) being made include the following (please note all applicable details):
Refusal
The patient has elected not to follow the recommendations of the provider as noted above and accepts responsibility for any consequences of that decision. The risks of not following the provider’s recommendations have been fully explained to the patient by the physician. The patient agrees that the provider named above, medical director Dr. Ken Ota, and company Prana Wellness Institute LLC DBA Prana IV Therapy shall not be held responsible or legally liable for the decision or any future consequences of the patient’s decision.

By signing below the patient acknowledges that s/he has read this information and has elected not to follow the provider's recommendations.
Patient Signature*
Provider Signature*