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Arizona Do Not Resuscitate Form (Letter Size)

The Arizona do not resuscitate form (letter size) is provided by Arizona Department of Health Services.

Arizona Do Not Resuscitate Form (Letter Size)
Arizona Do Not Resuscitate Form (Letter 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 (Letter Size)
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