State Of Arizona Prehospital Medical Care Form
ADVERTISEMENT
1S
O
A
TATE
F
RIZONA
PREHOSPITAL MEDICAL CARE DIRECTIVE (DO NOT RESUSCITATE)
(IMPORTANT—T
D
M
B
O
P
W
ORANGE B
)
HIS
OCUMENT
UST
E
N
APER
ITH
ACKGROUND
G
I
I
: A Prehospital Medical Care Directive is a document signed by you and
ENERAL
NFORMATION AND
NSTRUCTIONS
your doctor that informs emergency medical technicians (EMTs) or hospital emergency personnel not to resuscitate
you. Sometimes this is called a DNR – Do Not Resuscitate. If you have this form, EMTs and other emergency
personnel will not use equipment, drugs, or devices to restart your heart or breathing, but they will not withhold
medical interventions that are necessary to provide comfort care or to alleviate pain. IMPORTANT: Under Arizona
law a Prehospital Medical Care Directive or DNR must be on letter sized paper or wallet sized paper on an orange
background to be valid.
You can either attach a picture to this form, or complete the personal information. You must also complete the form
and sign it in front of a witness. Your health care provider and your witness must sign this form.
1.
My Directive and My Signature:
In the event of cardiac or respiratory arrest, I refuse any resuscitation measures including cardiac
compression, endotracheal intubation and other advanced airway management, artificial ventilation,
defibrillation, administration of advanced cardiac life support drugs and related emergency medical
procedures.
Patient (Signature or Mark): _____________________________________ Date:
:
OR
PROVIDE THE FOLLOWING INFORMATION
ATTACH RECENT PHOTOGRAPH HERE:
My Date of Birth ________________
My Sex
________________
HERE
My Race
________________
My Eye Color
________________
My Hair Color
________________
2.
Information About My Doctor and Hospice (if I am in Hospice):
Physician:
Telephone:
Hospice Program, if applicable (name):
3.
Signature of Doctor or Other Health Care Provider:
I have explained this form and its consequences to the signer and obtained assurance that the signer understands
that death may result from any refused care listed above.
Signature of Licensed Health Care Provider: ______________________________ Date:
4. Signature of Witness to My Directive:
I was present when this form was signed (or marked). The patient then appeared to be of sound mind and free
from duress.
Signature:
Date:
Developed by the Office of the Arizona Attorney General
Updated February 12, 2007
TERRY GODDARD
(All documents completed before February 12, 2007 are still valid)
PREHOSPITAL MEDICAL CARE DIRECTIVE (DNR)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal