Refusal of Treatment Form
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.
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
_________________________________________, 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.