Release From Responsibility Form

Date / Time

Date

Time

Patient Name

First

Last

Email *

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

First

Last

Witness Contact Number

RFR Officer Name

First

Last

RFR Incident Number

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