EMS Patient Refusal Form

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Date

Time

Incident # *

Patient Information

Patient Name *

Incident Address *

Patient Address *

Patient DOB *

Situation Involves *

Chest pain

Dyspnea

Altered Mental Status

Intoxication

Head Injury

N/A - None of the above

Assessment *

Alert *

Yes

Oriented to: *

Person: Yes No

Place: Yes No

Time: Yes No

Situation: Yes No

Vital Signs

Blood Glucose Normal: 60-300 mg/dL

O₂ Saturation Normal: ≥92%

Pulse Normal: 50-105 bpm

Systolic BP Normal: 90-190 mmHg

Diastolic BP Normal: 50-105 mmHg

Respirations Normal: 11-23 per min

Reason for No Transport *

Patient refuses transport against EMS advice

Patient does not desire transport to hospital via EMS and EMS provider agrees that the patient's alternative treatment/transportation plan is acceptable

EMS provider does not feel transport by EMS is necessary/indicated and patient agrees

EMS provider does not feel transport by EMS is necessary/indicated and patient desires transport

Naloxone Leave Behind Kit offered if "At-Risk Patient"?

Yes

Patient Education & Plan *

Risks explained to patient: *

Patient refused the following treatments/procedures: *

Patient's plan for seeking further medical evaluation: *

Patient understands clinical situation

Patient verbalizes logical reasons for desiring no transport

Patient verbalized understanding of risks

If patient lacks capacity or is pediatric, responsible adult family member or friend at the scene

Provider Information & Signatures

Patient refuses to sign

EMS Provider & Cert Number *

Witness

Medical Direction Contacted?

I understand that evaluation and/or treatment by Vermont-licensed Emergency Medical Services (EMS) personnel is not a substitute for care by my own physician or by a hospital emergency department. Although I am not being transported to a hospital by EMS, my condition may still warrant care by a physician. I am responsible for seeking the care I feel is necessary, and I have a plan for doing so. I also release the EMS personnel and organizations involved with my current situation from all claims resulting from my voluntary refusal of treatment and/or transport. I understand that if I change my mind, I can call 9-1-1 at any time.

If I request a copy of this form via email, I understand that email is not a secure form of communication and I accept the risks associated with receiving protected health information via email.

Patient lacks capacity to sign

Copy Delivery *

Copy provided via: *

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