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I am voluntarily refusing examination and/or treatment against the advice of Dr. A. Campen,
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and a representative of Vital Medical Services (VMS).
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I have been told about the risks and consequences involved in refusing examination
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and/or treatment at this time, the benefits of examination and/or treatment, and the
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alternatives, if any, to continued examination and/or treatment.
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I hereby release the physician, any other medical staff involved in my care, the jail
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and its employees and agents along with_____(specify agency)
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from all responsibility of any injury or ill effects which may result from this action.
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I understand that the physician named above and other medical staff who provide
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services to me are not employees or agents of VMS. They are independent contractors.
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TRANSLATION (If necessary). I have accurately and completely read the foregoing document to the signatory identified below in
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the patient/patient 's representative 's preferred language. He/She understood all terms and conditions and acknowledged
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his/her agreement by signing this document in my presence.
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Preferred Language If Not English
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Translator
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Signature of Patient
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Date
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Time
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Reason Patient Did Not Sign
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VMS Provider/Title/ID#
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Date/Time
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Police Officer/Custody Officer/ID#
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Date/Time
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I declare that I have explained to the patient the risks and consequences involved refusing
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examination and/or treatment at this time, the benefits of continued examination and/or
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treatment, and the alternatives , if any, to continued examination and/or treatment.
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Remarks
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