Discharge Against Medical Advice
I am signing this paper to show that I am leaving this hospital or health care center of my own free will. It is done against all medical advice. In doing so, I am releasing this hospital or health care center and the attending physicians from any and all claims that I may want to make.
I understand that further care has been recommended. My condition may worsen. This could cause me further bodily injury, illness, or even death. I do know that the medical staff has fully explained to me the risk that I am taking in leaving against medical advice.