Multiple Patient Refusal/release Form - Silver Cross Ems System Page 2
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2SILVER CROSS EMS SYSTEM
PAGE 2 OF 2
MULTIPLE PATIENT RELEASE FORM
Agency:______________________ Date:___/___/___ Type of Call:____________________ Number of Vehicles:_____
Location of Call:______________________________ Brief Description of Call:_________________________________
Total # of Patients:_______ # of Patients Transported:______ # of Patients Refusing:______ Unit #’s on Scene:_______
State Run Form #:___________ Agency Incident #:__________ Resource Hospital Log #:_____ Radio Contact:_____hrs
Call Recvd:_____hrs / Arrived Scene:_____hrs / Arrived Pt:_____hrs / Return Serv:_____hrs / Total Scene Time:_______
RELEASE FROM MEDICAL RESPONSIBILITY
I/we hereby refuse the emergency medical services, assessment, treatment and/or transportation to a medical facility
offered and advised by the above named service provider. I/we hereby release the Silver Cross EMS System, the provider
service, their personnel and employees, Silver Cross Hospital and its emergency nursing personnel and physicians of any
further responsibility and acknowledge that I have been advised by the ambulance personnel that I should have
emergency first-aid treatment, which I am refusing, and acknowledged by my signature below. I understand my refusal
may jeopardize the health of the patient, and I/we should consult a private physician regarding medical treatment. I hereby
release the above named parties from any and all claims of liability in connection with this incident and my signed refusal.
PRINT NAME
ADDRESS
CITY/STATE/ZIP
_________________________________
________________________________
___________________________
SIGNATURE:______________________________________ AGE:_____ SEX: M - F RELATIONSHIP:___________
PRINT NAME
ADDRESS
CITY/STATE/ZIP
_________________________________
________________________________
___________________________
SIGNATURE:______________________________________ AGE:_____ SEX: M - F RELATIONSHIP:___________
PRINT NAME
ADDRESS
CITY/STATE/ZIP
_________________________________
________________________________
___________________________
SIGNATURE:______________________________________ AGE:_____ SEX: M - F RELATIONSHIP:___________
PRINT NAME
ADDRESS
CITY/STATE/ZIP
_________________________________
________________________________
___________________________
SIGNATURE:______________________________________ AGE:_____ SEX: M - F RELATIONSHIP:___________
PRINT NAME
ADDRESS
CITY/STATE/ZIP
_________________________________
________________________________
___________________________
SIGNATURE:______________________________________ AGE:_____ SEX: M - F RELATIONSHIP:___________
AMBULANCE CREW MEMBERS
1.________________________________ System #______
2._______________________________ System #______
3.________________________________ System #______
4._______________________________ System #______
5.________________________________ System #______
6._______________________________ System #______
Manual Page: 300-65a
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