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NORTH COUNTRY REGIONAL REFUSAL FORM AND INSTRUCTIONS If YES is checked to any ofthe questions and the patient is refusing EMS transport they may not have adequate decision Medical Control and/or Law Enforcement should be contacted. D Patient deemed competent refuses all EMS care and ambulance transportation. o IV access 0 o Physical Exam Oxygen o Spinal Immobilization 0 Medications o EKG application o Vital Sign assessment o Other SECTION C P.

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