REQUEST TO WITHDRAW FROM TREATMENT Name of Patient I, ____________________________________________________________________________________________ ____________________________________________________________________, (Name of Patient/Parent/or Guardian of Minor) hereby give notice of intent to withdraw myself/my child within the next ______________ (Up to 72) hours from treatment. I understand that a member of the treatment staff may discuss this matter with me and make a decision during this time period. (Date) (Signature of Patient/Parent/or Guardian of Minor) (Signature of a Parent or Guardian of a Patient under 14 Years of Age) (Relationship to Minor, if Parent or Guardian) (Date Received) (Facility Staff Member Receiving Request) American LegalNet, Inc. www.FormsWorkFlow.com MH 781 F 2/87 PETICI�N PARA RETIRARSE DEL TRATAMIENTO Nombre del paciente____________________________________________________________________________________________ Yo, ____________________________________________________________________, (Nombre del paciente/padre/o tutor del menor) por medio de la presente informo de mi intenci�n de retirarme/retirar a mi hijo en las pr�ximas ______________ (hasta 72) horas del tratamiento. Entiendo que un integrante del personal de tratamiento posiblemente hable conmigo del asunto y tome una decisi�n en ese momento. (Fecha) (Firma del paciente/padre/o tutor del menor) (Firma de uno de los padres o tutor del paciente si es menor de 14 a�os de edad) (Relaci�n con el menor, si es padre, madre, tutor) (Fecha de recepci�n) (Miembro del personal que recibe la petici�n) American LegalNet, Inc. www.FormsWorkFlow.com MH 781 F-S 2/87