Fill and Sign the Eviction and Banning from the Good Samaritan Extended Care Form

DO-NOT-RESUSCITATE ORDER This do-not-resuscitate order is issued by ________________________________________ attending physician for________________________________________. (Type or print declarant's or ward's name) Use the appropriate consent section below:A. DECLARANT CONSENTI have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import._______________________________________ _______________(Declarant's signature) (Date)_______________________________________ _______________(Signature of person who signed for (Date)declarant, if applicable)________________________________________(Type or print full name)B. PATIENT ADVOCATE CONSENTI authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________(Patient advocate's signature) (Date)________________________________________ (Type or print patient advocate's name) C. GUARDIAN CONSENTI authorize that in the event the ward's heart and breathing should stop, no person shall attempt to resuscitate the ward. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________(Guardian's signature) (Date)________________________________________(Type or print guardian's name)_______________________________________ _______________(Physician's signature) (Date)________________________________________(Type or print physician's full name)ATTESTATION OF WITNESSESThe individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the declarant has (has not) received an identification bracelet. ______________________ ________ ______________________________(Witness signature) (Date) (Witness signature) (Date)______________________ ______________________(Type or print witness's name) (Type or print witness's name)THIS FORM WAS PREPARED PURSUANT TO, AND IS IN COMPLIANCE WITH,THE MICHIGAN “DO-NOT-RESUSCITATE PROCEDURE ACT".