Event PCR Form v2

The following Apply to myself or the patient on whose behalf I legally sign this document (Select all that apply)

I am refusing medical assessmentI am refusing medical treatmentI am refusing medical transportationI have received medical assessment and treatment, but decline medical transportation

I understand that EMS personnel are not physicians, nor are they qualified or authorized to make a diagnosis, and that their care is not a substitute for that of a physician. I recognize that I may have a serious injury or illness that could worsen without medical attention, even though I (or the patient on whose behalf I legally sign this document) may feel fine at the present time.

I understand that I may change my mind and call 9-1-1 if treatment or assistance is needed later. I also understand that treatment is available at an emergency department 24 hours a day or from my physician.

I acknowledge that this advice has been explained to me by EMS personnel and that I have read this form entirely and understand its provisions. I agree, on my behalf (and on the behalf of the patient for whom I legally sign this document), to release, indemnify and hold harmless all EMS providers and their officers, members, employees or other agents, and the base / modified base hospital, from any and all claims, actions, causes of action, damages, or legal liabilities of any kind arising out of my decision, or from any act or omission of the EMS providers or their personnel, or the base / modified base hospital or their personnel.

Patient Signature

Witness Signature

Name of Signor

First NameLast Name

Relationship to patient

Patient Care Report

Refusal of Care