Release of Medical Assistance form
|Date:||November 18, 1995|
A Release of Medical Assistance form, signed by Lisa McPherson.
I (or my guardian) have been informed of the reason I should go to a hospital for further emergency care.
I (or my guardian) have been informed of the evaluation and/or treatment that will/may occur when I get to the hospital.
I (or my guardian) have been informed of the potential consequences and/or complications that may result in my (or my guardian's) refusal to go to a hospital for further emergency care.
As a competent adult, I (or my guardian) fully understand all of the above, and am/is capable of determining a rational decision on my behalf.
I (or my guardian), the undersigned, have been advised that emergency medical care on my/the patient's behalf is necessary, and that refusal of recommended care and transport to a hospital facility may result in death, or imperil my/the patient's health by increasing the opportunity for consequences or complications. Nevertheless, and understanding all of the above, I (or my guardian), refuse to accept emergency medical care or transport to a hospital facility, assume all risks and consequences resulting from my (or my guardian's) decision, and release Pinellas County EMS from any and all liability resulting from my (or my guardian's) refusal. I have had the opportunity to ask all of the questions I feel necessary to provide this informed refusal.
There are notes written on the reverse side that have bled through; they are very hard to read, but appear to include the comments: "PT states she needs to talk ... people think she was crazy. Pt has agitated state ... Pt states she is Scientologist. ... Cont to ask me ... "
This is probably the Refusal form mentioned in the police interview with paramedic Bonnie Portolano<.