Fill and Sign the Arizona Prehospital Medical Care Directive Do Not Resuscitate Order Arizona Form

Arizona Prehospital Medical Care Directive (DNR) (6-3251 A.R.S.) I the event of cardiac or respiratory arrest, I refuse any resuscitation measures including cardiac compression, endotracheal intubation and other advanced airway management, artifcial ventilation, defbrillation, 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 ____ Eye color ________ hair color ______ race ______ Hospice program (if any) ________________________________ Name and telephone number of patient's physician ________ _________________________________________________________ (side two) 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. ________________________________ date __________ (Licensed health care provider) I was present when this was signed (or marked). The patient then appeared to be of sound mind and free from duress. ________________________________ date ___________ (Witness) C. A person who has a valid prehospital medical care directive pursuant to this section may wear an identifying bracelet on either the wrist or the ankle. The bracelet shall be substantially similar to identifcation bracelets worn in hospitals. The bracelet shall be on an orange background and state the following in bold type: Do Not Resuscitate Patient: _________________________________________ Patient's physician: _____________________________