Patient Refusal Information Sheet
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1Patient Refusal Information Sheet
Please Read and Keep This Form!
This form has been given to you because you have refused treatment and/or transport by the
Emergency Medical Service. Your health and safety are our primary concern. Even though
you have decided not to accept our advice, please remember the following:
Initials _____
1. The evaluation and/or treatment provided to you by the rescue squad is
not a substitute for medical evaluation and treatment by a doctor. We
advise you to get medical evaluation and treatment.
Initials _____
2. Your condition may not seem as bad to you as it actually is. Without
treatment, your condition or problem could become worse. If you are
planning to get medical treatment, a decision to refuse treatment or
transport by the EMS may result in a delay which could make your
condition or problem worse.
Initials _____
3. Medical evaluation and/or treatment may be obtained by calling your
doctor, if you have one, or by going to any hospital Emergency
Department in this area, all of which are staffed 24-hours a day by
Emergency Physicians.
You may be seen at these Emergency
Departments without an appointment.
Initials _____
4. If you change your mind or your condition becomes worse and you
decide to accept treatment and transport by the Emergency Medical
Service, please do not hesitate to call us back, by dialing 911. We will do
our best to help you.
Initials _____
5. Don’t wait! When medical treatment is needed, it’s usually better to get it
right away
6. If the box at the left has been checked, it means that your problem or
condition has been discussed with a doctor at the hospital by radio or
telephone and the advice given to you by the Emergency Medical Service
has been issued or approved by the doctor.
7. If the box at the left has been checked that indicates that you are the
patients legal guardian in this situation and are acting on behalf of the
patient.
By signing below you indicate that you have read and
understand
the
above
information
regarding
refusal
of
treatment/transport.
Guardian’s Name (printed):
Relationship to Patient:
Guardian’s Signature:
Date
----------------------------------------------------------------------------------------------------------------------------
I have received a copy of this Refusal Information Sheet
Patient’s Signature:
Date
Patient’s Name Printed:
Date
Provider’s Signature:
Date
Witness Signature:
Relationship to patient:
C10:117 (Rev. 7/02)
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