Refusal Checklist
Date *
MM
/
DD
/
YYYY
Time (of patient contact) *
Time
:
Run # *
Your answer
Age *
Your answer
DOB *
MM
/
DD
/
YYYY
Address of Incident *
Your answer
Reason for dispatch *
Your answer
Actual complaint / reason *
Your answer
18 Years of age or older *
If patient is an Emancipated Minor - How?
Your answer
Catchment *
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