Employee Refusal of Medical Treatment Form
Please fill out the following form if you refuse medical treatment as an employee.
Employee Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Department
Job Title
Reason for Refusal of Medical Treatment
*
Acknowledgment
*
I acknowledge that I have been informed of the potential risks and consequences of refusing medical treatment.
I understand that by refusing medical treatment, I may be putting my health at risk.
I agree to release the company and its representatives from any liability arising from my refusal of medical treatment.
Employee Signature
*
Date
 -
Month
 -
Day
Year
Date
Submit
Should be Empty: