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Patient Refusal Information Sheet Please Read and Keep This Form This form has been given to you because you have refused treatment and/or transport by the Emergency Medical Service. Guardian s Name printed Guardian s Signature Relationship to Patient Date ---------------------------------------------------------------------------------------------------------------------------I have received a copy of this Refusal Information Sheet Patient s Signature Patient s Name Printed Provider s Signature Witness Signature C10 117 7/02. Your health and safety are our primary concern* Even though you have decided not to accept our advice please remember the following Initials 1. The evaluation and/or treatment provided to you by the rescue squad is not a substitute for medical evaluation and treatment by a doctor. We advise you to get medical evaluation and treatment. 2. Your condition may not seem as bad to you as it actually is. Without treatment your condition or problem could become worse. If you are planning to get medical treatment a decision to refuse treatment or transport by the EMS may result in a delay which could make your condition or problem worse. 3. Medical evaluation and/or treatment may be obtained by calling your doctor if you have one or by going to any hospital Emergency Department in this area all of which are staffed 24-hours a day by Emergency Physicians. You may be seen at these Emergency 4. If you change your mind or your condition becomes worse and you decide to accept treatment and transport by the Emergency Medical Service please do not hesitate to call us back by dialing 911. We will do our best to help you. 5. Don t wait When medical treatment is needed it s usually better to get it right away 6. If the box at the left has been checked it means that your problem or condition has been discussed with a doctor at the hospital by radio or telephone and the advice given to you by the Emergency Medical Service has been issued or approved by the doctor. patients legal guardian in this situation and are acting on behalf of the patient. By signing below you indicate that you have read and understand the above information regarding refusal of treatment/transport. Your health and safety are our primary concern* Even though you have decided not to accept our advice please remember the following Initials 1. The evaluation and/or treatment provided to you by the rescue squad is not a substitute for medical evaluation and treatment by a doctor. The evaluation and/or treatment provided to you by the rescue squad is not a substitute for medical evaluation and treatment by a doctor. We advise you to get medical evaluation and treatment. 2. Your condition may not seem as bad to you as it actually is. We advise you to get medical evaluation and treatment. 2. Your condition may not seem as bad to you as it actually is. Without treatment your condition or problem could become worse. If you are planning to get medical treatment a decision to refuse treatment or transport by the EMS may result in a delay which could make your condition or problem worse.

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