Form Sample Ems Refusal Form Refusal Of Treatment, Transport And/or Evaluation
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1SAMPLE EMS REFUSAL FORM
REFUSAL OF TREATMENT, TRANSPORT AND/OR EVALUATION
!
PLEASE READ COMPLETELY BEFORE SIGNING BELOW
Because it is sometimes impossible to recognize actual or potential medical problems outside the
hospital, we strongly encourage you to be evaluated, treated if necessary, and transported to a
hospital by EMS personnel for more complete examination by a physician.
You have the right to choose to not be evaluated, treated or transported if you wish; however,
there is the possibility that you could suffer serious complications or even death from conditions
that are not apparent at this time.
By signing below, you are acknowledging that EMS personnel have advised you, and that you
understand, the potential harm to your health that may result from your refusal of the
recommended care; and, you release EMS and supporting personnel from liability resulting from
refusal.
PLEASE CIRCLE THE FOLLOWING THAT APPLY:
I refuse:
EVALUATION
TREATMENT
TRANSPORT
IF YOU CHANGE YOUR MIND AND DESIRE EVALUATION, TREATMENT, AND/OR TRANSPORT
TO A HOSPITAL, YOU MAY RE-CONTACT THE EMS SYSTEM AT ANY TIME.
Patient’s Printed Name ___________________________Age____DOB____Phone #_________
Patient’s Address_______________________________City___________State____Zip_______
Signature__________________________________ Relationship, if applicable______________
Witness Signature_________________________ Witness Printed Name___________________
Date and Time_________________________
BP________Pulse________Resp.________Skin________Pupils________LOC________
1.
Oriented to person, place, and time?
Yes
No
2.
Coherent speech?
Yes
No
3.
Auditory and/or visual hallucinations?
Yes
No
4.
Suicidal or homicidal?
Yes
No
5.
Able to repeat understanding of their condition and consequences of treatment refusal?
Yes
No
6.
Narrative: describe reasonable alternatives to treatment that were offered; the
circumstances of the call; specific consequences of refusal; and, names of family or
witnesses present:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
EMS Agency Name
Printed Crew Names
Signature of EMS Provider
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