Zone 1, Zone 1 Andres Bonifacio St,

Baybay City, 6521 Leyte

Phone No. 0926-799-4147
Fb: rabiesbusterABC
Email: rabiesbusteranimalbiteclinic@gmail.com

PATIENT REFUSAL OF TREATMENT FORM

Management/ Treatment refused;

o I refuse to be vaccinated with Anti-rabies Vaccine.

o I refuse to be infiltrated with Anti-rabies Serum.

o I refuse to be administered with Anti-tetanus Serum & Anti-tetanus Toxoid.

The doctor talked to me before I signed this form. The doctor/nurse explained my (the
patient’s) present medical condition very well.

I have been told that based on the doctor’s judgement the recommended management
treatment is necessary to treat/stabilize my (the patient’s) present condition.

The doctor also explained that I can go to nearest hospital’s emergency room anytime
when the need arises.

I will not hold anyone liable in case something untoward happens to me after my refusal;
henceforth my signing of this form was done out of my own free will despite my attending
doctor’s better judgement.

I have read and/or this has been read to me, the above PATIENT REFUSAL OF
TREATMENT/MANAGEMENT FORM and I fully understand everything that is written on this
form.

________________________________________ ______________
PRINTED NAME AND SIGNATURE OF PATIENT/LEGAL GUARDIAN DATE AND TIME

________________________________________ ______________
WITNESS DATE AND TIME