Patient ID Plate or Printed Name and SSN,
Address, and Daytime Telephone Number
PREPARED BY (Signature and Title)
DEPARTMENT/WARD/CLINIC
DATE (YYYYMMDD)
TIME
(Name of Medical Treatment Facility)
hospital/clinic authorities and my attending physician(s).
2. I have been advised of and understand the potential dangers involved in leaving the hospital/clinic at this time. The potential medical
risks that have been explained to me include:
3. I have been advised of and understand the follow-up actions recommended by my health care provider which include:
4. I hereby release the hospital/clinic, its staff and the Federal Government of all responsibility for any ill effects brought about by my
failure to continue medical evaluation and/or treatment as recommended.
(Signature of Patient/Date and Time) (Signature of Physician/Designee)
(Signature and Address of Witness)
(Representative's Name)
(Patient's Name)
(Name of Medical Treatment Facility)
3. I have been advised of and understand the potential dangers involved in having the patient leave the hospital/clinic at this time. The
potential medical risks that have been explained to me include:
4. I have been advised of and understand the follow-up actions recommended for the patient which include:
5. I hereby release the hospital/clinic, its staff and the Federal Government of all responsibility for any ill effects associated with failure
(Patient's Name)
(Signature of Patient's Representative/Date and Time) (Signature of Physician/Designee)
(Signature and Address of Witness)
For use of this form, see AR 40-68; proponent agency is the Office of The Surgeon General.
MEDICAL RECORD
DA FORM 5009, FEB 2004
PREVIOUS EDITIONS ARE OBSOLETE.
RELEASE AGAINST MEDICAL ADVICE
STATEMENT OF PATIENT RELEASING HOSPITAL/CLINIC FROM LIABILITY
UPON LEAVING HOSPITAL/CLINIC AGAINST MEDICAL ADVICE
STATEMENT OF REPRESENTATIVE OF PATIENT RELEASING
HOSPITAL/CLINIC FROM LIABILITY UPON LEAVING HOSPITAL/CLINIC AGAINST MEDICAL ADVICE
APD LC v1.01ES
1. This is to certify that I am leaving at my own insistence and against the advice of the
to continue 's medical evaluation and/or treatment as recommended.
without the authorization of hospital/clinic authorities and his/her attending physician(s).
1. Representative's name Relationship to the patient
2. I, , insist that be discharged/released from
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