Medical wavier form is filled out by a person so as to release the other person from the medical liability. This form is designed for providing the information about the risk prone activities. This form is also known as medical wavier release form and medical wavier liability form.
Sample Medical waiver form:
- Form Number: ___________
- Date: ____/____/____
- Details of the medical organization (clinic/ hospital/ nursing home):
Landline Number: _______________
Concerned E-mail id: ____________
Website address (if any): ______________
- Personal Information of the Patient:
Age: _________, Sex: __________ Blood group: ___________
Phone Number: _________________
E-mail id: ______________________
- Medical waiver form conditions:
Detailed medical history of the patient: _____________________
Current medicinal condition of the patient: ____________________
The patient is prone to allergies, if use: ___________________________ substances.
Meditation now being taken care of: ________________________________
Precautions to be taken care of: ____________________________
Suggested initial level treatment if any medical problem encountered: _____________
Hereby, the treatment of the patient with this hospital is completed. If any kind of health problem persists due to negligence, the hospital will not be responsible for that.
- Prepared By: _______________
- Signature of the specialist/ general physician: ______________
- Singed by the patient: __________________________________
- Signed by the Parent/ Guardian: ____________