Agrodrain: Medical Waiver Form

• Site

• Site Number

• Conducted on

  Date

• Supervisor/ Foreman

Medical Treatment Waiver

• Employee Name

• Position

• Date and Time of Incident

  Date

• 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

  Sign

• Date

  Date

• Foreman Signature

  Sign

• Date

  Date