Patient
Refusal

This form is being completed because I have refused medical care and/or treatment as noted above.

I understand that ambulance personnel are not physicians and are not qualified or authorized to make a diagnosis of my condition, and that their care is not a substitute for that of a physician.

I recognize that I may have a serious injury or illness, which could get worse without medical attention even though I may feel fine at this time.

I understand that I may change my mind and call 911 if I decide to accept treatment or need assistance later. I also understand that I may seek treatment from a physician or at an emergency department 24 hours a day.

I acknowledge that the ambulance crew has explained this advice to me and that I have read this form completely and understand its provisions.

I agree to release, indemnify, and hold harmless the ambulance service and its officers, members, or other agents from any and all claims, actions, cause of action, damages, or legal liabilities of any kind arising out of my condition or the refusal of medical care and/or transport, or of any act or omission of the ambulance service or its crew, even for negligence.