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Arizona Do Not Resuscitate Form (Letter Size)

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

Arizona Do Not Resuscitate Form (Letter Size) Page 2
(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 (on reverse side).
____________________________________ 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)
Arizona Do Not Resuscitate Form (Letter Size)
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