Refusal of Medical Treatment

Refusal of Medical Treatment

CS Construction, Inc.
Employee Name*
First & Last Name
Employee ID Number*
Ex: 2134
Injury Date*

MonthDayYear
Today's Date
On the date listed above, I suffered a minor work related injury while employed at CS Construction, Inc. I have been offered medical attention/treatment at CS Construction, Inc.’s expense by my supervisor/company representative. I do not wish to receive medical treatment at this time.
Injury Description:*
Please Describe In Detail What Happened
I acknowledge and understand my responsibility to inform my supervisor and/or Safety Department Representative if the need for medical treatment arises in the future as a result of this injury.
Today's Date

MonthDayYear
Date
Signature*

Clear
Should be Empty: