Refusal of Services

The Endeavor Emergency Squad personnel are providing this release to you because you wish to refuse treatment and/or transport. Please understand that your health and safety are our primary concern. Since you are declining further treatment and/or transport, please consider the following:

1. The EMS personnel have determined that an emergency physician should perform further medical evaluation and treatment.

2.The evaluation and/or treatment provided to you by the Endeavor Emergency Squad personnel are not a substitute for evaluation and/or treatment by a medical physician.

3.Your illness or injury may not seem as bad as it actually is. Without treatment, you could actually become worse. Refusing further evaluation and treatment may delay your recuperation and actually worsen your illness or injury.

4. If you should change your mind and wish to receive further treatment, you may call us back by dialing 911. We will return to provide quality care and prompt transport to the closest most appropriate medical facility.

You will be billed for assessment and refusal of care/transportation.

I request payment for medical benefits be made to the Endeavor Emergency Squad, Inc. I authorize the release of any medical information, insurance information, or other necessary documents to process this claim, or to determine benefits to the Endeavor Emergency Squad, Inc and/or its agents. I further acknowledge that I shall remain primarily responsible for any charges or unpaid balances. Upon receipt of an invoice reflecting amounts due, I must immediately pay the full amount of all unpaid charges.