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1. Patient Information: Complete identification details of the patient including full name, medical record number, national ID, age, and gender
2. Healthcare Provider Details: Information about the healthcare facility and the primary healthcare provider(s) involved
3. Treatment/Procedure Description: Detailed description of the medical treatment, procedure, or intervention being refused
4. Reasons for Recommendation: Medical explanation of why the treatment was recommended and its intended benefits
5. Consequences of Refusal: Clear explanation of potential risks and consequences of refusing the recommended treatment
6. Patient Declaration: Statement confirming that the patient understands the information provided and voluntarily refuses treatment
7. Capacity Confirmation: Confirmation that the patient has the mental and legal capacity to make this decision
8. Acknowledgment of Explanation: Confirmation that all explanations were provided in a language understood by the patient
9. Signatures: Dedicated section for patient/guardian signature, date, and time of signing
1. Guardian Information: Required when the patient is a minor, lacks capacity, or requires a legal guardian under Saudi law
2. Interpreter Declaration: Required when translation services were used to explain the form to the patient
3. Alternative Treatment Options: Optional section listing other available treatment options if relevant
4. Religious or Cultural Considerations: When refusal is based on religious or cultural grounds, documenting specific concerns
5. Emergency Contact Information: Optional section for emergency contact details
6. Future Care Provisions: Optional section specifying conditions under which the patient would reconsider treatment
1. Medical Information Sheet: Detailed medical information about the refused treatment/procedure and its necessity
2. Risk Documentation: Comprehensive list of potential risks and complications from refusing treatment
3. Patient Education Materials: Any educational materials provided to the patient about their condition and treatment options
4. Witness Documentation Form: Additional form for witness signatures if required
5. Arabic Translation: Arabic version of the form if the original is in English
Healthcare
Medical Services
Hospital Administration
Emergency Services
Primary Care
Specialized Medical Care
Mental Health Services
Pediatric Care
Elder Care
Rehabilitation Services
Legal
Medical Records
Risk Management
Quality Assurance
Patient Relations
Clinical Operations
Compliance
Healthcare Administration
Medical Affairs
Documentation
Medical Director
Hospital Administrator
Chief Medical Officer
Legal Compliance Officer
Risk Management Officer
Clinical Services Manager
Patient Rights Coordinator
Medical Records Manager
Quality Assurance Manager
Healthcare Facility Manager
Physician
Nurse Manager
Patient Relations Officer
Medical Legal Advisor
Clinical Documentation Specialist
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