REFUSAL TO CONSENT

The staff of First Responders has explained the risks and benefits of my refusal to follow to consent to the emergency treatment listed below. This person has advised me of the availability of and need for further medical examination and treatment by a physician at the closest appropriate emergency department. I fully understand what was discussed with me and that refusal of this treatment may jeopardize my health or life, but it is my wish that this refusal be honored. I fully accept responsibility for this refusal and for the consequences that may result from my refusal.

Emergency treatment or advice refused:

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Risks of refusal to consent:

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Patient name: ________________________________

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Patient/legally authorized representative signature Relationship to patient

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Witness Date

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First Responders Staff Date

FIRST RESPONDERS, INC