Release From Responsibility Form

Date / Time

Date

Time

Patient Name

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Last

Patient Acknowledged Checkboxes *

I acknowledge that I have declined to accept recommended treatment and/or transport for medical assessment, diagnosis and possible treatment by a physician and recognize the risk in doing so.
I, as a result of this form, release the City of Richmond, Richmond Fire-Rescue, the Emergency and Health Services Commission, its contractors and the consulting hospital from all responsibility for any ill effects which may occur from my action.

Witness' Name

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Last

Witness Contact Number

RFR Officer Name

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Last

RFR Incident Number

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