Signs & Symtoms
Signs & Symptoms
Loss of Consciousness
Head or Neck Pain
MOTOR VEHICLE ACCIDENT
- Rear End
- Side Impact
- Head On
PT Location in Crash
Vehicle Make and Model
Glasgow Coma Scale
Size & Location
- 5 Lead
- 12 Lead
- ET CO2
- Epi 1:1000
- Duo Neb
- Epi 1:10000
- Sodium bi carb
By signing the release, I agree that:
• I was offered transport to a hospital.
• The risks of refusing care and transport were explained to me.
• By refusing the care offered to me, I may increase the possibility of serious illness
• I was advised to seek medical attention.
• I was made aware of how to access follow-up care.
• I understand the directions given to me, and the risks involved with refusing
transport against the advice of EMTs.
• I am being left in the care of a responsible adult when appropriate.
If there is a return of symptoms or you become concerned, you should do one of the following:
• Contact your primary care doctor or their on-call answering service.
• Call “911” and ask for an ambulance.
• Visit an Emergency Department or Medical Clinic.
I hereby refuse treatment and/or transport to a hospital and I acknowledge that such treatment or transportation was advised by the emergency crew or physician. I hereby release such persons from liability for respecting and following my express wishes.