RELEASE
TEMPORARY LEAVE OF ABSENCE FROM HOSPITAL OR MEDICAL FACILITY
Name of Hospital:
______________________________________________.
Name of Patient:
_______________________________________________.
I, the above-named patient, having obtained
permission from the attending physician to be absent from hospital for
_______________ (Time Period of Absence),
assume all responsibility for myself during this temporary absence and release
_______________ (Name of Hospital),
its personnel and attending physicians from all responsibility during this
absence for my condition, including any deterioration of condition, accident,
and any acts of omission or commission on my part that cause harm to myself or
others.
_____________________________ ___________________
Signature Date
