Medical Treatment Waiver

Employee Name


Date and Time of Incident

By signing this form, I declare that medical treatment is not necessary for the injury/incident/illness from the aforementioned date. I elect not to receive medical treatment at this time. I also understand that if I decided to seek medical treatment, at any time, I must first inform the Foreman and the Safety Department prior to seeking medical treatment.

I have read and understand the above Agrodrain Medical Treatment Waiver and agree to abide by the procedures set forth.

Employee Signature
Foreman Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.