Medical Treatment Refusal Form

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Region*

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Personal Information

Employee Name*

First Last

Date*

Title*

Contact #*

SSN# (Last 4 only)*

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District Manager*

Company Division*

Casing

Tubing

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Emergency assistance and/or treatment has been offered to you by our company personnel and/or by an independent medical professionals. By signing this “Medical Treatment Refusal Form” you have indicated that you do not want treatment and have refused assistance.

Refusal Statement

I hereby release TRK Enterprises Inc. dba Pipe Pros from any and all liabilities resulting from my refusal of emergency care and transportation. I am being advised through this document that my condition may be serious and could require immediate medical treatment. I further understand that I am being directed to contact my personal physician or an emergency facility physician as to my present condition.

I voluntarily acknowledge my participation of this form and I truly understand its content.*

Agree

Employee Name*

First Last

Witness Name*

First Last

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