Refusal of Treatment or Refusal to be Transported to The Hospital Statement

Employee Name(Required)

First Last

Address(Required)

Street Address City Province Postal Code

Phone Number(Required)

I declare that I have voluntarily refused treatment or transportation to hospital despite the advice of first aiders; I therefore absolve my employer and his staff and any person who acted as a first aider from any liability arising from such refusal.(Required)

Refused Treatment

Transportation to Hospital

Name(Required)

First Last

Date(Required)

Signature(Required)