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Get and Sign S SV EMS REFUSAL of CARE FORM 850 a 2014-2022

Get and Sign S SV EMS REFUSAL of CARE FORM 850 a 2014-2022

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Areas identified on this checklist must be specifically documented on the Patient Care Report PCR. The patient/guardian was informed of the risks of this refusal and refused to sign this form when asked by the EMS providers. Has a significant medical concern or mechanism of injury including all ALS/LALS chief complaints. EMS personnel do not concur with the refusal. medical authority on scene in close proximity to the pt. Print Name of Witness Updated 01/2014 S-SV EMS RAS/AMA ASSESSMENT...
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