Pre-Hospital Patient Release Against Medical Advice (AMA)

Refusal of Medical Treatment and Transportation

This is to certify that I release the City of Escondido and its employees, and the Base Hospital and its staff, and the Base Hospital Physician, from liability for any claim arising from, or associated with, my injuries or medical condition; and I refuse further treatment and medical transportation to the hospital, even though I am informed and I am aware that my injuries or medical condition may be serious and may require further treatment.

I acknowledge that I have read and understand the terms of this release, and I have signed it voluntarily. I agree that this release shall be binding on my relatives, heirs, legal representatives and assigns.

Note to Patient: You will provide an electronic signature and at that time will be noted as to which of the advisories you are providing the signature for.