Pre-Hospital Medical Care Directive

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:

Name and telephone number of patient's physician:

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: __________

Signature of 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: __________

Signature _________________________

______________ Statutes, Section __________