Patient's Consent, Request, or Refusal to Transfer

TRANSFER CONSENT

I __________________________________________________ acknowledge that my medical condition has been evaluated and explained to me by the Emergency Department physician and/or my attending physician who has recommended that I be transferred to the services of Dr. ____________________ at ____________________. The potential benefits of such transfer outweigh the potential risks of not being transferred. These risks have been fully explained to me and I fully understand them. With this knowledge and understanding, I agree and consent to be transferred.

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Signature of Patient or legally responsible individual

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Date and Time

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Witness Signature

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Date and Time

TRANSFER REQUEST

I __________________________________________________ acknowledge that my medical condition has been evaluated and explained to me by the Emergency Department physician and/or my attending physician who has recommended and offered to me further medical examination and treatment. The potential benefits of such further medical examination and treatment as well the potential risks associated with transfer to another facility have been fully explained to me and I fully understand them. In spite of this understanding, I refuse to consent to the further medical examination and treatment which has been offered to me, and request transfer to ____________________.

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Signature of Patient or legally responsible individual

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Date and Time

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Witness Signature

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Date and Time

TRANSFER REFUSAL

I __________________________________________________ acknowledge that my medical condition has been evaluated and explained to me by the Emergency Department physician and/or my attending physician who has recommended that I be transferred to the services of Dr. ____________________ at ____________________. The potential benefits of such transfer, the potential risks associated with such transfer, and the probable risks of not being transferred have been fully explained to me and I fully understand them. Even though Dr. __________________________________________________ believes it is in my best interest to be transferred, I refuse to be transferred and I request instead to continue receiving treatment at ____________________.

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Signature of Patient or legally responsible individual

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Date and Time

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Witness Signature

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Date and Time