AOR Form "*" indicates required fields PART I: PATIENT INFORMATIONEmail* Patient Name* Patient ID No* Patient Address*Patient Contact* PART II: TO BE FILLED BY PATIENT / CONSENTING PARTYConsent I* We / I acknowledge that *the above mentioned patient / I may have *medical problem(s) and/or injur(ies) which could require medical attention and I have been advised to seek treatment.Consent II* We/I do not allow the attending medical Staff to activate an ambulance nor convey *us/me to the hospital for medical attention despite being advised against making the refusal and given the assurance that the hospital would be adequately equipped to handle the condition. I am fully informed that such refusal is against medical advice.Consent III* I confirm that I have been informed and fully understand the consequences of the above actions and that refusal to receive the necessary medical care and assistance could be detrimental to *the patient’s/my health , and may even lead to permanent disability or death and accept full responsibility for my / our decision. I hereby release and absolve both the medical staff , event organizer and the company from any responsibility and liability for any adverse effects that may result from such a decision and shall indemnify the attending Medical personnel , event organizer and the company against any liability whatsoever.Consent IV* *We/I have been informed to consult a doctor or call SCDF 995 if the patient’s/my condition worsen.Consent V* *We/ I have read and fully understood the “Release of Liabilty” Clause as stated above.PART III : SIGNATORYThe above information for the discharge / refusal against medical advice is explained, given to and agreed by;Requestor’s Name* Requestor’s ID No* Relationship to patient* Contact Number* Signature*Upload Photo of Requestor ID (Front)*Max. file size: 64 MB.Upload Photo of Requestor ID (Back)*Max. file size: 64 MB.
