Patient Refusal (English)

Stedman Volunteer Fire Department Inc.

Patient Care Refusal Form
ACKNOWLEDGMENT OF INFORMATION

I have been offered an evaluation, medical care, and/or transportation to a medical facility; However, I reject the services offered. I have been informed and understand the risks and consequences of refusing care/transportation, including
the fact that a delay in treatment and/or transportation by means other than an ambulance could be dangerous to my health and, in certain circumstances, include disability and/or death.
RELEASE OF LIABILITY

By signing this form, I release Stedman Volunteer Fire Department Inc. and its response personnel from any liability or medical claim resulting from my
decision to refuse offered medical care/transportation.

I have read and understand the “Acknowledgment of Information” and “Disclaimer.”
Date*

MonthDayYear
Date
Name of patient*

First NameLast Name
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Date of Birth*

MonthDayYear
Date
Patient's phone number
Please enter a valid phone number.
Patient's Signature

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Patient Refused to Sign
Name of guardian or parent

First NameLast Name
Phone number of the guardian or parents
Please enter a valid phone number.
Signature of guardian or parent

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Witnesses Name*

First NameLast Name
Witnesses Signature

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Emergency Personnel Complete the Information Below.
Incident Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Report Number (Ask Dispatch or Look at Freedom App.)*
Responding Primary Unit Number*
Responders Name*
Responders Signature*

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Should be Empty:

Stedman Volunteer Fire Department Inc.