8/14/2019 Va Tech Standby Release

1/2

----------------------------VIRGINIA TECH RESCUE SQUAD - RELEASE FORM

RELEASE OF LIABILITY FOR STANDBY PATIENTS ______ OateEMS Providers:INAME (LAST, FIRST, M.I.): Oisp.

ALS / BLS / NAIPATIENT NUMBER:IEVEL OF CARE:

Anival0 SEX; IAGE: f't.ACE OF EMS CONTACT: Trans.DOB: t-!!: zM / F Arr iv Dest.w-z Q~ O M E ADDRESS: PATIENT RELEASED TO: Clearedw Ui= pALONE o OTHER EMS UNIT

8/14/2019 Va Tech Standby Release

2/2

Reminder for Refusals1. Patient must be of egal age. Virginia law states that any individual 14 years of age, pregnan t female. or malTied

teenager are of egal age to consent to treatment or refusal of treatment.2. Patient may not be impaired by alcohol or drugs, either legal or illegal.3. Patient's refusal of reatment at this time does not deny them from treatment at a Iatar time.