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 ____

Eye color ________ hair color ______ race ______

Hospice program (if any) _____________________

Name and telephone number of patient’s physician _______________________________________________________________

______________________________________________________________________________________________________________________________

(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.

________________________________ 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)