Voluntary Refusal of Medical Assessment or Care

Cabalgatas San Pablo – Salento

Date: __________________ Time: __________ Route/location: __________________

Participant full name: ______________________________________________

ID/passport: __________________________ Phone: _______________________

Incident description

Briefly describe the fall, impact, symptom or event, including time and location:

____________________________________________________________________
____________________________________________________________________

Recommendation made

Recommended: ☐ medical assessment ☐ medical care ☐ transfer/emergency response ☐ other: __________________

Recommendation explained by: _______________________________________

Voluntary decision

I confirm that the recommendation for medical assessment or care was explained to me and that I am currently choosing to decline it voluntarily. I had the opportunity to ask questions and my decision was not obtained through pressure.

I understand that some symptoms or injuries may appear or worsen later, that declining assessment may make it harder to document the incident and assess a potential insurance claim, and that coverage is determined by the insurer under the policy. I have been advised that I may seek medical care independently and should request help if symptoms appear or worsen.

This record documents my decision. It is not a waiver of legal rights or a general release of liability.

Participant signature: __________________________ ID: __________________

Name/signature of person explaining recommendation: __________________________

Witness, if applicable: __________________________ ID: __________________

If participant is a minor, representative’s name, capacity and involvement: __________________________