Employee Refusal Of Medical Treatment Form

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Employee Refusal of Medical Treatment Form
HR
Employee
I have been advised by my Manager/Supervisor that I may seek medical treatment for the injury that may have occurred on the
job per the below listed information. I do not think medical treatment is needed at this time, but I will inform my Manager/Supervisor
immediately should the need arise.
Employee’s Printed Name
:
Date of Injur
, per Employee
Time of Injury, per Employee
y
AM
PM
:
:
List Specific Body Part(s) (example: right hand, index finger):
List Specific Injury Type (example: scratch, burn, cut):
Manager/Supervisor
Comments
:
Employee Signature:
Date:
Manager/Supervisor Signature:
Date:
Please save and email this document to as an attachment.
If you have any questions, please contact us at 800.922.4133
or via e-mail at
670 N. River Street, Suite 406, Plains, PA 18705 | o. 800.922.4133 | f. 800.955.8144 |
Rev. 0 16

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