Medical Transport Refusal Form
For patients or guardians to formally refuse medically recommended transport. Please complete all sections.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Guardian Full Name (if applicable)
First Name
Last Name
Relationship to Patient
*
Please Select
Self
Parent
Legal Guardian
Spouse
Other
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Reason for Refusal of Transport
*
Was the patient (or guardian) informed of the potential risks of refusing transport?
*
Yes, fully informed
No, declined information
Medical Provider Name
*
By checking this box, I acknowledge that I am refusing the recommended medical transport and understand the potential risks involved.
*
I acknowledge and refuse medical transport
Submit Refusal
Should be Empty: