Printable Refusal Of Medical Treatment Form - _____ i am provided with this refusal form and information so i may understand the recommended treatment and the consequences of refusing treatment. I do not wish to seek medical attention at this time, but Use this form if an employee has a minor injury and they do not feel that they need medical treatment. My medical condition has been explained to me by my medical provider. Remember to complete an incident report form as soon as possible. In this circumstance, consider asking the patient to sign a specific refusal form. The reason for and/or the purpose of the recommended test/treatment/procedure has been explained to me. Web (please print) provide a detailed description of the injury below: Web refusal of medical treatment form (mployee’s name (please print) employer’s rep/supervisor’s name: If the employee’s injury is obvious, get medical attention and/or call 911, if necessary.
Use this form if an employee has a minor injury and they do not feel that they need medical treatment. _____ i am provided with this refusal form and information so i may understand the recommended treatment and the consequences of refusing treatment. My medical condition has been explained to me by my medical provider. I have had an opportunity to discuss and ask questions concerning the recommendations and alternative treatment recommendations. Use this form if an employee has a minor injury and they do not feel that they need medical treatment. The risks/benefits of the recommended test/treatment/procedure have been. _____ _____ _____ _____ _____ _____ _____ employee signature date. The reason for and/or the purpose of the recommended test/treatment/procedure has been explained to me. If the employee’s injury is obvious, get medical attention and/or call 911, if necessary. In this circumstance, consider asking the patient to sign a specific refusal form. Remember to complete an incident report form as soon as possible. The nature of the recommended test/treatment/procedure have been explained to me. Web refusal of medical treatment form (mployee’s name (please print) employer’s rep/supervisor’s name: Web a record of the patient’s refusal of the treatment/testing plan or advice. I have been advised by my employer that i may seek medical treatment for the event described above. I do not wish to seek medical attention at this time, but (see our sample form “ refusal to consent to treatment, medication, or testing.”) Web (please print) provide a detailed description of the injury below: