MEDIGY LLC
Against Medical Advice (AMA)
Your physician has recommended a specific course of therapy, method of treatment or a means diagnosing and/or treating a medical condition for the patient names above. This is a medical decision made by the physician based upon the findings of an examination and/or diagnostic testing. The physician believes this recommendation is in the patient's best interest. Medigy, LLC has provided equipment to adequately meet these recommendations.
The patient has elected not to follow the recommendations of the physician as noted above and elected to return the device and/or failed to adequately use the device. The patient accepts responsibility for any consequences of that decision. The risks of not following the physician's recommendations have been fully explained to the patient of Medigy , LLC. The patient agrees that the physician and/or Medigy, LLC shall not be held responsibile or legally liable for the decision or any future consequences of the patient's decision.
By signing below the patient acknowledges that he/she has read this information and has elected not to follow the physician's recommendations.
electronically signed
