PRE-HOSPITAL MEDICAL CARE DIRECTIVERead the
WARNING! first.
PRE-HOSPITAL MEDICAL CARE DIRECTIVEIn 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 |
