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State of Arizona Prehospital Medicare Care Directive (Do not Resuscitate)


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Office of the Attorney General of Arizona, Mark Brnovich	 	
Life Care Planning Packet: Prehospital Medical Care Directive	 	
Section 7: Page 1 of 1	 	 	Updated 06/16	 	
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 sup port drugs and related emergency medical 
Patient  Signature:    Date: 	    	 	
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 a 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. 
Signat ure:  Date:  	
GENERAL INFORMATION AND INSTRUCTIONS	: A Prehospital Medica	l 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	t 	
withhold medical interventions that are necessary to provide comfort care or to alleviate pain. IMPORT ANT	: 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 par t 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
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