Title Page
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Conducted on
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Prepared by
Refusal of Medical Treatment or Observation
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Select date
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Bryan Carrillo
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I, hereby acknowledge my refusal of medical treatment and/or observation offered to me at the expense of Rival Well Services Inc. for the incident/accident that I was involved in. By signing this form, I realize that I do not necessarily affect my later eligibility for treatment or observation. I acknowledge that my supervisor(s), in good faith, have offered and made available to me an opportunity to seek necessary medical treatment and/or observation. I am aware that by declining medical treatment at this time, that my employer, will not be responsible for any medical expenses or lost wages. At a later time, I may request from my employer, via my supervisor, a medical authorization to obtain medical treatment and/or observation for the above described injury.
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Employee signature
