ข้าพเจ้าขอแสดงเจตนาปฏิเสธการ □ ผ่าต

ข้าพเจ้าขอแสดงเจตนาปฏิเสธการ
□ ผ่าตัด (โปรดระบุ)..................................................................................................................................................................................................................
□ ทำหัตถการ (โปรดระบุ)..........................................................................................................................................................................................................
□ ตรวจวินิจฉัยทั่วไป (โปรดระบุ)................................................................................................................................................................................................

ผลลัพธ์ (อังกฤษ) 1:

I salute the intent to protest □ ผ่าตัด (โปรดระบุ).................................................................................................................................................................................................................. □ ทำหัตถการ (โปรดระบุ).......................................................................................................................................................................................................... □ ตรวจวินิจฉัยทั่วไป (โปรดระบุ)................................................................................................................................................................................................

ผลลัพธ์ (อังกฤษ) 2:

My intention to deny the
surgery □ (please specify) ...................................... .................................................. .................................................. .................................................. ......................
□ procedures (please specify) ..................... .................................................. .................................................. .................................................. ...............................
□ General Diagnosis (please specify).............................................. .................................................. .................................................. ..............................................