PRE-HOSPITAL CARE DIRECTIVE

PRE-HOSPITAL CARE DIRECTIVE 2017-05-02T08:41:05+00:00

SAMPLE FORM

PREHOSPITAL MEDICAL CARE DIRECTIVE

(A.R.S. §36-3251)

(Note: Must be an ORANGE background)

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 ____

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)