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This is to certify that I, _________________________ acknowledge I am not injured and that there is no emergent need for treatment and or transport.  I request that staff provide assistance to lift and return me to a place of comfort. As needed, I have made or will make arrangements for alternative means of transportation and will contact the health care provider of my choice (personal physician, urgent care center, emergency department, or other healthcare provider) to address my medical needs. I acknowledge that I have been informed of the following:

  1. The nature and potential of illness or injury
  2. The potential risks of refusing and or delaying treatment and or transportation up to and including death
  3. The availability of ambulance transportation to a hospital for treatment
  4. Staff have evaluated me within their scope of practice and within their standard of care based upon and I understand that this evaluation is not a diagnosis


___        Released in care of self
___        Released in care of friend, relative or staff  

Name_________________________ Relationship_________________________

Patient/Resident/Responsible Party Signature______________________________  

Must be signed by the patient or legal guardian/POA      

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