Life Care Planning: Office of Arizona Attorney General,
DNR - Updated 03/2020 Mark Brnovich
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PREHOSPITAL MEDICAL CARE DIRECTIVE
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's Printed Name: _________________________________________
Patient’s Signature: _________________________________________Date: _______________
*If I am unable to communicate my wishes, and I have designated a Health Care Power of
Attorney, my elected Health Care agent shall sign:
Health Care Power of Attorney Printed Name: _________________________________________
Health Care Power of Attorney Signature: ___________________________________________
PROVIDE THE FOLLOWING INFORMATION OR ATTACH A RECENT PHOTO:
Date of Birth_____________
Sex____________________
Race___________________
Eye Color _______________
Hair Color ______________
INFORMATION ABOUT MY DOCTOR AND HOSPICE (if I am in Hospice):
Physician: Telephone: _________________
Hospice Program, if applicable (name):
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: _________________
SIGNATURE OF WITNESS OR NOTARY (NOT BOTH)
I was present when this form was signed (or marked). The patient then appeared to be of sound
mind and free from duress.
Witness Signature: Date: _______________
NOTORIAL JURAT:
STATE OF ARIZONA ) ss
COUNTY OF ______________)
________________________________________________
Patient’s Name/Health Care Power of Attorney Name
Subscribed and sworn (or affirmed) before me this ______________ day of __________, 20 ______
Notary Public Signature: ____________________________My Commission Expires: ____________
