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Refusal of Treatment Form

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DIRECTIONS: Students have the right to refuse medical treatment and/or transportation; however, if they exercise this right, they must sign the “Refusal of Treatment” form.

When a student refuses to sign this form, write “REFUSED” on the signature line.  Sign your name and have a second witness co-sign this form.

  

College of the Canyons

Student Health & Wellness Center

26455 Rockwell Canyon Road

Santa Clarita CA  91355

 

Refusal of Treatment Form

 

I, _________________________________________, hereby release College of the Canyons from any liability of medical claims resulting from my refusal of emergency care and/or transportation to the nearest recommended medical facility.

I further understand that I have been directed to contact my personal physician as to my present condition as soon as possible.  I have received a verbal explanation of the potential consequences of my refusal of emergency care treatment.

 

 

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Student/Patient Signature                        

 

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Witness

 

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Date