PRE-HOSPITAL MEDICAL CARE DIRECTIVE
Read the
WARNING! first.
PRE-HOSPITAL 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:__________________________________
Date:__________________
(Signature or mark)
Attach recent photograph
here or provide all of the
following information below:
DOB: ______________
Sex: ______________
Eye color: ______________
Hair color:______________
Race: ______________
Hospice program (if any):
______________________________
Name and telephone number of patient's
physician:
___________________________________________________
Pre-hospital Medical Care Directive
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: ____________________
Signature of 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: ____________________
Signature of Witness:
___________________________
Arizona Revised Statutes, Section 36-3251 |
