Released at scene — no further care neededReleased — advised to see a doctor / urgent careReturned to event activitiesReleased to parent / guardian (name above)
Transferred to EMS — unit: __________ time: ______Destination hospital: ________________________Refused care or transport — complete Section 8Left before care was complete
Consent, Refusal & Privacy
Confidential · Protected Health Information
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7. Consent to Assessment & Care
I agree to be assessed and to receive first aid and emergency care from Castle Branch First Response medics. I understand that:
The medics are trained and certified emergency care providers. They are not physicians, and the care given here does not replace care by a doctor or hospital.
I may ask questions, refuse any part of the care, or stop care at any time.
The medics may advise me to see a doctor or to go to a hospital, and may call 911 if they believe my condition requires it.
Patient could not give consent (unconscious, confused or in immediate danger, and no parent / guardian available). Emergency care given under implied consent. Medic initials: ______
8. Refusal of Care or Transport (complete only if care or transport is refused)
Patient refuses:All assessment / careTransport by EMSSpecific care: ______________________
Medic confirms:Patient is 18 or older, or the parent / guardian is the one refusingPatient is alert, oriented and appears able to understand the decision (no apparent impairment from injury, illness, alcohol or drugs)Risks of refusing were explained in a language the patient understands, including: ____________________________________
Patient statement: I have been told about my condition and that refusing care or transport may cause my condition to get worse, and could result in permanent injury or death. I understand that I can change my mind at any time, return to the medical station, or call 911. I am making this decision on my own.
Patient refused to sign
9. Privacy & Release of Information
Your health information is kept confidential and stored securely. Castle Branch First Response shares it only:
With EMS, hospital or other health care providers who take over your care;
When required by law (for example, mandatory reports or a valid subpoena or court order); or
With your written permission, below.
The event organizer receives only a summary that does not identify you, unless you give permission here. You may ask for a copy of this record by calling (832) 907-1484.
I authorize release of this record to:Event organizer / venue (incident report)Event insurance carrierOther: ____________________No one — do not release
10. Medic Certification
I certify that this record is complete and accurate to the best of my knowledge.
