Section 7: Page 1 of 1
U
pdated 06/16 - Form
Made Fillable by eForms
PREHOSPITAL MEDICAL CARE DIRECTIVE (DO NOT RESUSCITATE)
(IMPORTANT—THIS DOCUMENT MUST BE ON PAPER WITH ORANGE BACKGROUND)
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: ____________________________
Patient's Printed Name: ________________________
PROVIDE THE FOLLOWING INFORMATION:
OR
Date:
___
2.
Information About My Doctor and Hospice (if I am in Hospice):
Physician: Telephone:
Hospice Program, if applicable (name):
PREHOSPITAL MEDICAL CARE DIRECTIVE (DO NOT RESUSCITATE) (Last Page)
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 a Licensed Health Care Provider: Date:
4.
Signature of Witness to My Directive:
GENERAL INFORMATION AND INSTRUCTIONS: A Prehospital Medical Care Directive is a document signed by you
and your doctor that informs emergency medical technicians (EMTs) or ho
spital 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 no
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.
NOTE: At least one adult witness OR a Notary Public must witness the signing of this document. The witness or Notary Public
CANNOT be anyone who is: (a) under the age of 18; (b) related to you by blood, adoption, or marriage; (c) entitled to any part of your
estate; (d) appointed as your representative; or (e) involved in providing your health care at the time this form is signed.
My Date of Birth
My Sex
My Race
My Eye Color
My Hair Color
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:
ATTACH RECENT PHOTOGRAPH HERE:
