1. Interpreter Declaration: Required when the patient's primary language is not English or when an interpreter was used during the consent process

2. Legal Representative Authorization: Required when the patient is a minor or lacks capacity to make medical decisions

3. Religious or Cultural Considerations: Include when refusal is based on specific religious or cultural beliefs that need to be documented

4. Emergency Contact Information: Optional section for listing emergency contacts who are aware of the patient's decision

5. Revocation Section: Optional section allowing the patient to document if they later change their mind and accept treatment

1. Medical Information Sheet: Detailed medical information about the refused treatment/procedure and its implications

2. Risk Assessment Form: Detailed documentation of specific risks discussed with the patient

3. Patient Education Materials: Copies of any educational materials provided to the patient about the refused treatment

4. Legal Representative Documentation: Copies of legal documents proving authority of legal representative (if applicable)