Arizona Do Not Resuscitate Order (DNR) Form

In modern society, you can make any decisions concerning you and your life. Sometimes these decisions are very difficult but necessary. We are talking about the Do Not Resuscitate (DNR) form.

In Arizona, this form can be used by any citizen who has decided not to use artificial life support if a respiratory arrest or lack of cerebral activity is recorded.

This DNR form is used if the maintenance of life is impractical; that is, there will be more harm than benefit from resuscitation. Incurable patients decide to stop resuscitation.

Resuscitation can also include:

  • Cardiac compressions
  • CPR
  • Artificial ventilation
  • Defibrillation and other procedures

Laws and Requirements

There are special rules for completing and signing this form. In Arizona, §36-3251 of State Law regulates this. The text provides the wording to be used for this document.

Additionally, it is important to note that the form must be printed on an orange background. The paper size must be in either letter or wallet size.

Signing Requirements

According to the law, the form must be signed by a:

  1. Patient
  2. Licensed physician
  3. Witness

Moreover, if the patient has appointed an agent to make health care decisions, this agent must sign the form. This refers to the case when the patient can no longer do this due to their condition.

Revocation of DNR Form in Arizona

It is possible to cancel the DNR action at any time. To do this, the patient (or the designated agent) must either create a new document or cancel the previous one. But first of all, you need to notify the attending physician about the change in the decision. The doctor will then remove the order from the medical records.

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Download your fillable Arizona DNR form in PDF format.

How to Fill Out Arizona DNR Form

We’ve designed a step-by-step illustrated guide for you to fill out DNR in Arizona.

  • Append Patient’s Details and Signature

Filling out the document begins with the provision of personal information about the patient. It is necessary to indicate:

  • Date of birth
  • Sex
  • Race
  • Eye color
  • Hair color

You also need to attach your recent photo, signature, and printed name.

step 1 to filling out the arizona dnr form - append patients details and signature

  • Add Hospice Information

If the patient is in a hospice, it is also necessary to indicate the physician’s name and phone number. Also include the hospice program, if any.

step 2 to filling out the arizona dnr form - add hospice information

  • Get the Doctor’s Signature

The attending physician or other licensed health care provider must also write their name and sign the document.

step 3 to filling out the arizona dnr form - get the doctors signature

  • Get Witness’s Signature

The document must be signed in the presence of a witness or a notary public agent.

step 4 to filling out the arizona dnr form - get witnesss signature

Note that not every person can be a witness. According to the rules, the witness must be:

  • An adult over 18 years old
  • Someone other than a blood relative, spouse, or someone related by adoption
  • Someone who does not claim the estate of the patient
  • Someone who is not the patient’s representative
  • Someone who is not involved in treatment or health care provision of the patient

The witness also signs and dates the document.

Published: Oct 18, 2021