Medical Treatment Refusal Form

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Personal Information

Employee Name*
MM slash DD slash YYYY
Please enter a number from 0000 to 9999.
Company Division*

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.*
Employee Name*
Witness Name*
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