DECLINATION OF MEDICAL TREATMENT
I understand that I am declining medical treatment for a work related injury at this time. By declining medical treatment at this time, I am not forfeiting my right to seek medical treatment at a later date if I feel my condition persists or gets worse.
MAD-Declination of Treatment Form
Declination of Medical Treatment Form
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended
take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or
or other applicable laws. You should also seek your own professional advice to determine if the use of such
permissible in your workplace or jurisdiction.