Right Of Refusal Of Medical Aid printable pdf download

Right Of Refusal Of Medical Aid

RIGHT OF REFUSAL OF MEDICAL AID

Show Name: _________________________________________________

I hereby refuse the first aid treatment recommended to me by the First Aid Person employed by my

production for the illness or injury incurred by me on this date.

In signing this waiver, I release the First Aid Person, the Production and its personnel from any

liability resulting from this refusal to accept such first aid treatment.

______________________________________________

_____________________________

Injured’s or Guardian’s Signature

Date

________________________/_____________________

______________________________

Injured’s Name (print)

Injured’s Cell #

Job Title or Position

__________________________________________

______________________________

Guardian’s Name in case of minor

Relationship to Injured

__________________________________________

First Aid Person Signature

__________________________________________

First Aid Person Name (print)

__________________________________________

Witness Signature

____________________________/_______________________

Witness Name (print)

Witness Cell #

This form should be signed, dated and returned to the Production Safety Representative.

NOTES: ____________________________________________________________________

____________________________________________________________________

(Form 16) Right of Refusal of Medical Aid

Right Of Refusal Of Medical Aid