Calontir Chirurgeons' Patient Encounter Form (Page 3 of 3) in pdf

Refusal of Treatment

Kingdom of Calontir

Patient Information:

Person’s SCA Name: _______________________________________________________________________

Person’s Modern Name:

First: ___________________ MI ____ Last: ____________________________

Date of Birth: ____ / ____ / ______

Age: ______

Is this person a Minor? Yes / No

Address

Street _______________________________________________________________________

City __________________________________________ State _____ Zip Code _______

Telephone

Home: ____ - ____ - _______

Cell: ____ - ____ - _______

Emergency Contact Information:

Modern Name: ________________________ Phone: Home: ____ - ____ - ____ Cell: ____ - ____ - ______

Refusal Statement:

“I do hereby acknowledge that I have been advised that evaluation, treatment, and/or transportation to a

medical facility are necessary for my condition. I have also been informed of the potential risk involved

if I do not comply with this advice.

I hereby state my refusal to follow the advice given me by the first aid personnel and refuse further

evaluation, treatment, and/or to a medical facility.

I, by the above statements, absolve and hold harmless of any responsibility all first aid personnel, and

their agents, from any ill effects of my actions.

Patient Name (please print): _________________________________________________________________

Patient Signature:

_______________________________________________________________________

Parent’s / Guardian’s Name (please print): _____________________________________________________

Parent’s / Guardian’s Signature: _______________________________________ Date: ____ / ____ / _____

Witness

The patient and/or their parent or guardian named above has refused first aid services and has refused to sign this

form acknowledging her/his act. Signing this form I hereby attest to these facts and the accuracy of the information

herein.

Witness Name:

_________________________________________________________________________

Witness Signature:

__________________________ Date: ____ / ____ / ______ Time: ____ : ____ am / pm

Calontir Chirurgeons' Patient Encounter Form Page 3