Medical Treatment Refusal Form

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.

  • Select your location
  • Personal Information

  • MM slash DD slash YYYY
  • 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.
  • This field is for validation purposes and should be left unchanged.