AMA / LAMA Discharge Form

Against Medical Advice — formal documentation of patient-initiated discharge

This form creates a permanent medico-legal record. Ensure all fields are accurately completed and the patient or legal guardian has been fully informed of the clinical risks before proceeding.

Patient & Admission

Patient Name

IP Number

Ward / Bed

Treating Doctor

Date & Time of AMA

AMA Type

Patient / Representative

Name of Person Requesting Discharge *

Relation to Patient

ID Proof Type & No.

Contact Number

Clinical & Reason Documentation

Reason Given by Patient / Family *

Additional Details

Current Clinical Status at Time of Departure *

Risks Explained to Patient / Family *

I confirm that all risks of early discharge have been clearly explained to the patient / legal guardian, in their preferred language, and they have confirmed understanding.

Patient / guardian acknowledges that they are voluntarily choosing to leave against medical advice and release the hospital and treating team from liability arising from this decision.

Doctor Documenting *

Witness Name