Refusal to Seek Medical Treatment

Name

First

Last

I am a healthcare worker employed by Craft Health. My employer, Craft Health, has offered to provide me with information on receiving medical care in regards to the accident report I completed on (enter date of the incident below).

However, I, of my own free will and accord, and despite my employer’s offer, have elected to not receive medical treatment at this time. I am also aware that even though I am waiving medical treatment at this time, I can still seek medical treatment at a later date. I understand that by typing my name below and clicking on "Submit", I am electronically signing this document and am certifying that the above information is true and correct. A copy of this form will be emailed to you and HR.

Date