Arizona Do Not Resuscitate Order
This document serves as a Do Not Resuscitate Order in accordance with the specific requirements set forth by the state of Arizona. Its purpose is to inform medical professionals of the patient's wish to forego resuscitation attempts in the event of cardiac or respiratory arrest. Please ensure all information provided is accurate and complete.
Personal Information
Patient Name: ___________________________
Date of Birth: ___________________________
Address: ____________________________________________________
Medical Information
Primary Physician: ___________________________
Physician Phone Number: ___________________________
Medical Conditions: ________________________________________
Do Not Resuscitate (DNR) Order Declaration
I, ___________________________, hereby declare my decision to forgo resuscitation including cardiopulmonary resuscitation (CPR) by medical personnel or emergency services in the event my heart and/or breathing stops. This decision is informed and voluntary, and complies with the Arizona Revised Statutes.
Legal Witness
This document requires the acknowledgment of a legal witness to ensure its validity. The witness confirms that the patient signing this DNR order did so voluntarily and without coercion.
Witness Name: ___________________________
Relationship to Patient: ___________________________
Date: ___________________________
Physician Verification
As the patient's physician, I verify that the patient's decision to have a Do Not Resuscitate Order has been discussed with me and I concur with the patient's decision based on his/her current medical condition and prognosis.
Physician Name: ___________________________
Date: ___________________________
Signature: ___________________________
Instructions for Revocation
A Do Not Resuscitate Order can be revoked at any time by the patient or their legal representative. To revoke, the patient or representative must inform the treating physician or medical personnel verbally or by destroying this document.
Disclaimer
This template is provided for informational purposes only and does not constitute legal advice. Individuals are encouraged to consult with a legal professional or healthcare provider to ensure the form complies with current Arizona laws and medical guidance.