MANPOWER • TRAVEL & TOURS • LOGISTICS

RELEASE FROM RESPONSIBILITY

Date: ________________________ 20____________ Time: ___________am/pm

This is to certify that I, ________________________________________________________________________________

is refusing __ REFERRAL FOR MEDICAL TREATMENT __ TRANSPORTATION __ TREATMENT

against the advice of the attending Occupational Health Nurse and of the EVERTRUST BUSINESS SOLUTIONS INC., and
when applicable, the Evertrust Business Solutions - Occupational Health Committee Representative.

I acknowledge that I have been informed of the following:

1. The nature and potential of the illness or injuries.

2. The potential risks of delaying treatment, rehabilitation, and transportation, up to and including death.
3. The availability of ambulance transportation to a hospital for treatment.

Nevertheless, I assume all risks and consequences of my decision, including further physical deterioration, loss of limb,
paralysis, and even death, and hereby release the attending Occupational Health Nurse and the Evertrust Business
Solutions, and when applicable, the Evertrust Business Solutions - Occupational Health Committee Representative from
any ill effects which may result from my refusal.

SIGNED: ___________________________________________

CONSENT FROM: ____________________________________

RELATIONSHIP TO PATIENT: ___________________________

WITNESS: __________________________________________

WITNESS: __________________________________________

Refusal must be signed by the patient; or by the nearest relative or legal guardian in the case of a minor, or when patient is
physically or mentally incompetent.

__ Patient refuses to sign release despite efforts of attending Occupational Health Nurse and of the EVERTRUST
BUSINESS SOLUTIONS INC. to obtain such signature after informing patient of concerns listed in number 1, 2, and 3
above.
_____________________________________________________________________________________

GUIDELINES - Patient Refusal Documentation

In addition to those items normally documented (chief complaint, history of present illness, mechanism of injury, physical
assessment, etc.) the following items should be recorded, regardless of patient's cooperation:
- Mental Status (orientation, speech, etc.)
- Suspected presence of alcohol or drugs
- Patient's exact words, (as much as possible) in the refusal of care OR the signing of the release form.
- Circumstances or reasons (including exact words of patient, if possible) for INCOMPLETE ADVISEMENT
(risk of injury, abusiveness, cruelness, risk of injury other than from patient, etc.)
-Advice given to patient's guardian(s)

ebse-osh1-tr-001-form.

__________________________

By:_______________________

MANILA: Head Office: Suite 101 Columbian Building, 160 West Avenue Corner EDSA Quezon City 1100 Philippines
CAVITE: Satellite Office: FCR Building, 224 SALITRAN I Emilio Aguinaldo Highway Dasmarinas City 4114, Philippines
PAMPANGA: Satellite Office: 05-L Berthaphil, Clark Center, CLARK FREEPORT ZONE, Clark Field Pampanga
TELEPHONE NUMBERS:  (+632) 415-8525  (+632) 415-3583; TELEFAX:  (+632) 376-0786