Home > Legal > Will and Trust Form > Do Not Resuscitate Form > Arizona Do Not Resuscitate Form > Arizona Do Not Resuscitate Form (Wallet Size)

Arizona Do Not Resuscitate Form (Wallet Size)

The Arizona do not resuscitate form (wallet size) is provided by Arizona Department of Health Services.
Arizona Do Not Resuscitate Form (Wallet Size)
Arizona Do Not Resuscitate Form (Wallet Size)
PREHOSPITAL MEDICAL CARE DIRECTIVE
(side one)
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: _______________________________________ Date: ______________
(Signature or mark)
Attach recent photograph here
or provide all of the following
information below:
Date of Birth _______________
Sex _________ Race ________
Eye Color _________________
Hair Color _________________
PHOTO
Hospice Program (if any) ____________________________________________
Name and telephone number of patient's physician ________________________
_________________________________________________________________
Arizona Do Not Resuscitate Form (Wallet Size)
Previous

1/2

Next