Sabetha EMS

Refusal of Treatment and Transport

Run Number

Patient Name

Date

I, , have been advised by Sabetha Ambulance Service Emergency medical Technicians, as to the advisability of, the risk and complications inherent in, the expected benefits of, as well as the alternatives to and their risks and benefits, and the probable consequences of not receiving emergency medical services.

I have requested, against the advice of attending EMTs that emergency medical services not be proved to me, and I release Sabetha Ambulance Service, City of Sabetha Kansas, Sabetha EMT Association, it's personnel, severally and individually, from any liability of any nature for any injury or complication of any kind that may result, directly or indirectly, by reason of my refusal to permit the above-mentioned emergency medical services and I waive all rights of action I may now have or later aquire as a result of this refusal.

This refusal is made with me with full knowlege that I may suffer adverse medical consequences as a result of the decision.

Patient or authorized representitive Signature

Name of person signing & relationship to patient

To Be Completed By EMS

The patient is 18 + YOA, alert, oriented and competent to the best of my judgement. Or, a competent parent or legal guardian is refusing care for the patient.

The patient was informed that EMS will return if called, should they change thier mind or their condition worsens.

Signature of EMS representitive

Name of EMS representitive signing

Signature of Witness

Name of witness signing