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Printable Refusal Of Medical Treatment Form

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Web informed refusal of treatment to be signed by patient, provider and witness to document the discussion between the patient and provider on risks of declining. You can also download it, export it or print it out. Date supervisors name phone number supervisors signature date hr signature date. Web benefits and potential consequences of refusal (i.e.

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_____ description of incident and. I am refusing medical treatment. Brief narrative description of the incident: Worsening of medical condition, etc.) explained to the youth:

Employee’s Name (Print):_ _____ Department:

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