An against medical advice (AMA) form is what a patient signs when they leave the hospital or turn down care you recommend. The AMA discharge note beside it shows how you got there: capacity for this decision, the risks in the patient’s terms, the alternatives, and the care you still gave. Copy the free form and note, see a heart attack leaving the emergency department and cellulitis leaving on day 2 of IV antibiotics, and check what each part needs.
Blank against medical advice form template
FreeAGAINST MEDICAL ADVICE FORM Refusal of recommended care, with the clinician's note Patient: [Full name] Date of birth: [Date] Record number: [Number] Date and time: [Date, and time of the discussion] Where: [Emergency department, ward, clinic, or other setting] Clinician: [Name, credentials, role] Also present: [Nurse, family or friend at the patient's request, interpreter, or none] PART 1: THE PATIENT'S FORM My condition: [What the care team thinks is wrong, or what still needs to be ruled out, in plain words] What my care team recommends: [Staying in hospital, a test, a treatment, a procedure, or waiting for a result] Why they recommend it: [What it should find, treat, or prevent] What I am declining: [All further care, or the specific part declined] What I still accept: [A dose before leaving, prescriptions, a follow-up visit, or nothing] What could happen if I decline: [Each risk in plain words, including serious illness, permanent disability, or death where that is true] Other options I was offered: [Each option, such as a shorter stay, a different treatment, or help with my reason for leaving, and my answer] I have been told about my condition, the care recommended, what could happen if I decline it, and the other options. My questions have been answered. I am choosing to [leave the hospital, or decline the care above] against the advice of my care team. I know I can change my mind and come back at any time, and I will be cared for when I do. Patient: [Signature, printed name, date and time] If the patient declines to sign: [The patient's words, the time, and who heard them] Clinician: [Signature, printed name, role, date and time] Witness: [Signature, printed name, role, date and time, where your organization's policy asks for one] Interpreter: [Name or ID, language, and in person, phone, or video, or not used] PART 2: THE CLINICIAN'S NOTE CLINICAL PICTURE Presentation and findings: [Key history, exam, and results that make the recommendation urgent] Working diagnosis: [Diagnosis, or what is still being ruled out] Treatment so far: [Tests done, treatments with dose and time, and results still pending] RECOMMENDATION AND DECISION Recommended: [The care recommended, and what it should achieve] Declined: [Exactly what the patient declines, and when they said so] Accepted: [What the patient still agrees to] CAPACITY FOR THIS DECISION Checked for: [Alcohol or drugs, glucose, oxygen, pain, delirium, head injury, hearing, and language] Understands: [The patient's own account of the condition and the recommendation] Appreciates: [The patient's words showing the risks apply to them] Reasons: [How the patient weighed staying against leaving, in their words] Choice: [The decision, and whether it stayed the same over time and with different staff] Finding: [Has capacity for this decision, or the concern, who assessed further, and the result] THE DISCUSSION Risks explained: [Each risk, in the words used, most serious first] Benefits of staying: [What the recommended care offers, in the words used] Patient's reasons: [In the patient's words] Alternatives offered: [Each alternative, and the patient's answer] Questions asked: [The patient's questions, and the answers given] Others involved: [Senior clinician, consultant, social worker, or family with the patient's agreement, or none] CARE STILL PROVIDED Before leaving: [Doses given with times, and IV lines removed] Prescriptions: [Each medicine, dose, how often, and for how long] Follow-up: [With whom, when, whether booked, and who calls if the patient doesn't come] Results pending: [Each result, who will check it, and the confirmed phone number] Return advice: [The signs to come back for or call 911, and what the patient said back] Invitation to return: [Told they can come back at any time, and the words used] Copies given: [This form, discharge instructions, and prescriptions] DEPARTURE Left at: [Time, how, and with whom] Condition on leaving: [Symptoms and last vital signs] Told: [Admitting team, consultant, primary care clinician, or none] Signed: [Clinician name, credentials, date and time of this entry]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Emergency department, late evening, emergency physician and cardiology fellow
52-year-old man, arrived by ambulance at 9:10 p.m. with 2 hours of central chest pressure spreading to the left arm, with sweating, that began at rest. High blood pressure; smokes 20 cigarettes a day. BP 156/94, HR 92, SpO2 97% on room air. ECG at 9:14 p.m.: sinus rhythm at 90, 1 mm horizontal ST depression in V4 to V6, no ST elevation. High-sensitivity troponin T 48 ng/L at 9:20 p.m. and 79 ng/L at 10:20 p.m., both above the assay’s 99th percentile of 14 ng/L, with a rise of 31 in an hour. Working diagnosis: non-ST-elevation myocardial infarction.
Recommended, and agreed with the cardiology fellow, Dr. Farah Haddad, at 10:40 p.m.: admission to the cardiac care unit, a heparin infusion, continuous heart monitoring, repeat ECGs and troponin, and coronary angiography within 24 hours. At 11:15 p.m. he said he would not stay the night. Declines: admission, heparin, monitoring, and angiography tonight. Accepts: a first dose of atorvastatin here, prescriptions, a nitroglycerin spray, and coming back at 8 a.m. tomorrow to be admitted.
In these words: “This is a heart attack. The blood test shows heart muscle is being damaged, and the number went up in an hour. The danger tonight is a bigger heart attack, or your heart going into a rhythm that stops it pumping. That can kill you within minutes, and at home no one can shock your heart back. If you survive a bigger one, your heart can be left weak for good, and you could be short of breath for the rest of your life.” Benefits of staying: monitoring that catches a dangerous rhythm in seconds, a blood thinner to stop the clot growing, and an angiogram to find and open the blocked artery, usually with a stent.
“My wife can’t be alone at night. Since her stroke she gets up to use the bathroom, and she fell and broke her hip last year doing that. Her care worker left at 11, and the neighbor can only stay until midnight.” Offered: the on-call social worker to find an overnight carer; none available before 8 a.m. A call to family; his brother, 3 hours away, will be there by 8 a.m. An ambulance to bring his wife in to stay with him; he declined, as hospitals make her distressed and confused. A senior opinion: Dr. Haddad came down at 11:30 p.m. and repeated the advice; his answer was the same.
Alert and calm, GCS 15. Pain-free since nitroglycerin at 9:30 p.m. No alcohol today; glucose 6.8 mmol/L (122 mg/dL); SpO2 97%; no sedating medicines given. English is his first language; hearing normal. Understands: “It’s a heart attack, a smaller type, and the blood test went up. You want to keep me on the monitor and do an angiogram.” Appreciates: “If I go home I could have a bigger one tonight, or my heart could stop, and I could die before anyone gets to me. I get it.” Reasons: “If I stay, she’s alone all night and she’ll fall again. One night, then I’m back at eight.” Choice: the same to the nurse, to me, and to Dr. Haddad, over 45 minutes. Finding: has capacity to refuse admission tonight.
Form read through with him at 11:50 p.m. Signed by the patient at 11:55 p.m., then by me. Witness: Maria Lopez, RN, who heard the risks explained and saw him sign. No interpreter needed. Copy given.
Before leaving: aspirin 325 mg chewed at 9:24 p.m.; nitroglycerin 0.4 mg under the tongue at 9:30 p.m.; atorvastatin 80 mg at 11:52 p.m. Takes no sildenafil or similar medicines. Prescriptions: aspirin 81 mg daily from tomorrow; atorvastatin 80 mg every night; nitroglycerin spray 0.4 mg under the tongue as needed for chest pain, shown how to use it. Follow-up: come straight to the emergency department at 8 a.m.; triage and Dr. Haddad expect him, and a cardiology bed is requested. If he hasn’t arrived by 9 a.m., cardiology will call his cell, number confirmed. Return advice: call 911, and don’t drive, if chest pain lasts more than 5 minutes, isn’t better 5 minutes after one spray, or comes with breathlessness, sweating, fainting, or a racing heart. He said it back. Invitation: “Come back at any time tonight, even at 3 a.m. You won’t be in trouble. We want you here.” Copies: this form, discharge instructions, and prescriptions.
Left at 12:05 a.m. by taxi, pain-free; BP 138/86, HR 78. Told: Dr. Haddad and the charge nurse. A copy of this note to his family doctor in the morning. Note written 12:20 a.m.
Medical ward, mid-morning, hospitalist with the charge nurse
34-year-old woman with type 2 diabetes on metformin; HbA1c 8.6% in August. Admitted yesterday at 7 a.m. from the emergency department with 3 days of a red, hot, swollen left shin after a scratch while gardening. On admission: T 38.7 °C (101.7 °F), HR 112, white cell count 15.8 × 10⁹/L, glucose 15.2 mmol/L (274 mg/dL); redness 14 by 9 cm, edge marked in pen; no abscess on bedside ultrasound; no blisters, crepitus, or pain beyond the redness. Treatment so far: IV cefazolin 2 g every 8 hours, 4 doses, the last at 7:30 a.m. today. Today: last fever 38.2 °C (100.8 °F) at 2 a.m.; HR 94; redness at the pen line, not spreading but not yet shrinking; white cell count 12.9. Blood cultures from admission: no growth at 24 hours.
Recommended: 24 to 48 more hours of IV cefazolin, until she has been fever-free for 24 hours and the redness is shrinking, with correction insulin to bring her glucose down; then tablets to finish at home. At 9:40 a.m. she asked to go home today. Declines: more IV antibiotics and the rest of the stay. Accepts: antibiotic tablets, a leg check tomorrow, a note for work, and a call if the blood cultures grow anything.
In these words: “The infection isn’t clearly getting better yet; you had a fever eight hours ago. Tablets may not hold it. If it spreads, it can get into your blood and make you very sick within hours. Rarely, an infection like this goes into the deep tissue and needs an operation, and people can lose part of the leg or die from it. Diabetes makes all of this more likely, and high sugar makes it harder for your body to fight the infection.” Benefits of staying: higher antibiotic levels from the drip, a doctor checking the leg twice a day, and her glucose brought under control.
“I’ve missed two shifts at the warehouse. My supervisor says a third and I’m done, and I can’t lose this job.” Her shift starts at 3 p.m. today. Offered: a medical note for her employer; taken, though she says it won’t change his mind. The social worker; declined, no time. IV ceftriaxone once a day at the outpatient infusion clinic; declined, as it is two buses and an hour each way, every day. One follow-up visit she can fit before work; accepted.
Alert, dressed, sitting on the bed. T 37.4 °C; glucose 9.6 mmol/L (173 mg/dL); no sedating medicines; no signs of delirium. Understands: “The drip is stronger than the pills. The red hasn’t gone down yet, so it could spread or get in my blood.” Appreciates: “With my diabetes it’s worse for me. I know people lose legs.” Reasons: “If I lose the job, I lose the apartment. I’ll take every pill, keep the leg up, and come straight back if it goes past the line or I get a fever.” Choice: the same at 9:40 and at 10:30 a.m., and to the charge nurse. Finding: has capacity to decline further inpatient care.
Declined to sign at 10:40 a.m.: “I’m not signing something that says I’m being stupid.” Told her that signing isn’t needed for her prescriptions, her follow-up, or to come back. Witness: Daniel Kim, RN, charge nurse, who heard the discussion and her refusal to sign. Signed by me. Copy of the unsigned form given to her.
Before leaving: IV cefazolin 2 g at 7:30 a.m.; cannula removed at 10:50 a.m., tip intact. Leg photographed beside the pen line, with her consent. Prescriptions: cephalexin 500 mg four times a day for 7 days, first dose at 1:30 p.m. today; continue metformin 1,000 mg twice a day. Follow-up: rapid follow-up clinic tomorrow at 12:30 p.m., booked, to check the leg against the line and the photo; her family doctor within a week for her diabetes. Results pending: blood cultures, final in 5 days; the ward team will call her if they grow anything; cell number confirmed. Return advice: come back to the emergency department the same day if the redness spreads past the line, the pain gets much worse, or she has a fever of 38 °C (100.4 °F) or more, chills, or vomiting; call 911 if she feels faint or confused. Keep the leg raised on breaks and at night. She said it back. Invitation: “If you change your mind, even tonight after work, come back, and we’ll restart the drip.”
Left at 11:05 a.m., walking, with a friend driving. T 37.4 °C, HR 90, BP 124/78. Told: the rapid follow-up clinic, and her family doctor by discharge summary sent today.
The care you recommend, and the exact part the patient is declining. Patients often refuse one piece of a plan and accept the rest.
Avoid: “Refuses treatment.” Say which treatment. A patient leaving before a third troponin may still take aspirin, a prescription, and a cardiology visit.
The risks of declining, in the words you used at the bedside, so a reader can tell what the patient actually heard.
Avoid: “Risks, benefits, and alternatives discussed.” That records that a talk happened, not what was said. Quote your words.
Why the patient wants to leave, in their words, and what you offered to make staying possible, or leaving safer.
Avoid: Skipping the why. Untreated pain, withdrawal, or someone waiting at home is often fixable, and fixing it is the surest way to keep the patient.
Whether the patient can make this decision now. A capable adult can refuse any care, however unwise it looks; a patient who lacks capacity can’t give an informed refusal.
Avoid: “Alert and oriented.” Orientation doesn’t show the patient understands this decision. If capacity is in doubt, stop and complete a full capacity assessment.
The form shows the conversation took place. Your note is the stronger record, and a patient who won’t sign still gets the same care.
Avoid: Holding back prescriptions or discharge papers until the patient signs. A signature is never a condition of care.
Leaving against advice doesn’t end your duty of care. Give the safest plan the patient will accept, and write down exactly what it was.
Avoid: A bare “return if worse.” Name the signs, say where to go and when to call 911, and tell the patient they’ll be welcomed back.
When and how the patient left, their condition, and who now needs to know.
Avoid: Writing the note hours later as if it were live. Give the time of the talk, the time the patient left, and the time you wrote it.
A signature with no record of the talk shows almost nothing. Write the recommendation, the risks you named, the patient’s reasons, and what they said back.
“Risk of adverse cardiac events” isn’t what the patient heard. Write the words you used, such as “a bigger heart attack tonight, or dying at home,” when that is true.
No prescriptions, no follow-up, and no return advice punish the patient and raise the very risk you warned about. Give the safest plan they will accept.
Leaving against advice isn’t a reason insurers refuse a claim, and saying so pressures the decision. Keep the talk on the clinical risk, and send billing questions to the billing office.
Knowing the date and place doesn’t show the patient understands this decision. Ask them to tell you the risks, quote what they say, and check for alcohol, low glucose, low oxygen, and delirium.
“If you leave, you can’t come back” is wrong and dangerous. Tell the patient they can return at any time, write that you said so, and let the team know if they plan to.
Vero Scribe drafts the AMA form and note in your template from the conversation, with the patient’s consent, or from your dictation: the recommendation, the risks in the words you used, the patient’s reasons, and the care they still accepted. You review and edit every section, then copy it into your record or export it to Word or PDF for signing. Vero works in 60+ languages.
Write it at the time, in your own words. Name the recommendation and the exact care declined; the patient’s capacity for this decision, with their own words as evidence; the risks you named, in the words you used; the patient’s reasons; and the alternatives you offered. Then record the care you still gave: doses, prescriptions, follow-up, pending results, and return advice. End with the time they left and who you told.
The patient’s details; the condition and the care recommended; exactly what is declined and what is still accepted; the risks of declining in plain words, including death or disability where that is true; the alternatives offered; a line saying the patient can change their mind and come back at any time; and signatures from the patient, the clinician, and a witness where your policy asks for one, with space to record a refusal to sign.
Write “declined to sign,” the patient’s words, the time, and who heard them, and have a witness sign if your policy asks for one. Then give the same prescriptions, instructions, and follow-up you would have given anyway. The signature is only evidence that the talk happened; a complete note is better evidence.
Leaving against advice isn’t, by itself, a reason insurers refuse payment. The belief is common, even among doctors, but a 2012 study of 526 patients who left one US teaching hospital against advice found no claim refused because the patient left; the few early denials were billing errors (Schaefer and colleagues, Journal of General Internal Medicine). Telling a patient they’ll owe the whole bill pressures their decision. Keep the talk on the clinical risks, and send coverage questions to the billing office.
Yes. Leaving against advice doesn’t end your duty of care. Give the treatment they will accept before they go, prescriptions for what they need, a follow-up visit or call, a plan for results still pending, and clear return advice. Tell them plainly that they can come back at any time.
Then they can’t give an informed refusal, and an AMA form doesn’t fit. Treat what you can, such as low glucose, low oxygen, or pain, and reassess. If they still lack capacity, involve their substitute decision-maker, give emergency treatment that can’t wait, and follow the emergency and mental health rules where you practice. Record it in a capacity assessment.
Yes. Copy it, or download it as a Word or text file. No account needed.
A patient’s authorization to release health information: who sends and receives it, what goes, sensitive records, purpose, end date, rights, and the release log.
Consent to a procedure or treatment: benefits, risks, alternatives, capacity, signatures, and the discussion note.
A parent names another adult to consent to their child’s care: dates, what it covers, health details, and signatures.
Screening questions, consent or declination, and a record of each dose: lot, expiry, site, observation, and the next dose due.
Consent to clinical photos, video, or audio: what is recorded, each use chosen separately, the device, storage, and withdrawal.
The longer guide: the rules where you practice, unsigned forms, patients who leave before the talk, and handing over pending results.
ED notes, dispositions, and refusal notes drafted from the bedside conversation.
Admission, progress, and discharge notes on the ward, drafted for your review.
Patient-specific consent forms from your organization’s own templates.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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