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MIDSTATE EMS Patient Refusal Form Patient name PCRRun - midstateems 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the patient's name and PCR/Run number in the designated fields at the top of the form.
- Fill in the date and time of service, along with the EMS agency name and printed EMT name & number.
- In the 'Patient Refusal' section, check all applicable boxes for care that is being refused, such as blood pressure checks or IV starts.
- Ensure that the patient signs on the 'Responsible Party' line to acknowledge their refusal of care.
- Complete any additional instructions provided, ensuring that all necessary information is documented accurately.
- Finally, have a witness sign and date the form to confirm that they observed the patient signing.
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