Arizona DNR (Do Not Resuscitate) Form

📄 Download Arizona DNR Form (Prehospital Medical Care Directive)

❓ What Is a DNR Form?

A Do Not Resuscitate (DNR) form is a medical order that clearly instructs emergency personnel not to attempt cardiopulmonary resuscitation (CPR) if your heart stops or you stop breathing.

It applies to:

• CPR

• Defibrillation

• Advanced cardiac life support (ACLS)

It does not affect your right to receive other types of care like pain relief, oxygen, wound treatment, or comfort measures.

⚠️ Who Should Use a DNR?

This form is typically used by:

• Individuals with advanced or terminal illnesses

• Those with serious heart or lung disease

• People who do not want CPR attempted

• Hospice patients or residents of long-term care facilities

If you’re healthy or unsure, a Living Will or POLST may be a better place to start.

✍️ Step-by-Step Instructions

Top of the Form: DNR Identification

This large, bright section is for visibility by first responders. Do not alter it.

Section 1: Personal Information

What it asks:

• Your full legal name

• Date of birth

• Gender

• Phone number

• Home address

Helpful Tip: Use your full legal name and current contact details. This ensures emergency personnel can match the form to you.

Section 2: Signature and Affirmation

This is the most important section. You must affirm that you do not want CPR performed if your heart or breathing stops.

• Signature of the individual You sign here to declare your wishes

• Date of signature

• One of the following must also sign:

  • A licensed Arizona physician, nurse practitioner, or physician assistant

  • OR your health care power of attorney or legal guardian

  • OR, if you're unable to sign, another adult may sign at your direction

Helpful Tip: If you're working with a care team, they can help coordinate this. The signature confirms you’re mentally competent and making this decision voluntarily.

Section 3: Witness (Optional but Encouraged)

You may include a witness signature to further validate the form. This is especially helpful if:

• You’re unable to sign yourself

• You’re in a care facility

• Your representative is signing on your behalf

Bottom of the Form: Physician/Provider Information

If your healthcare provider is signing, they must fill out this part:

• Name

• Contact information

• License number

• Signature

• Date

Helpful Tip: This section must be filled out by a licensed Arizona provider for the form to be legally valid.

✅ After You Complete the Form

1. Print on Colored Paper Arizona law requires the DNR form to be printed on ORANGE paper (or bright pink, coral, or other fluorescent color). This makes it easily visible in an emergency.

2. Keep It Visible and Accessible

   • Place it on your refrigerator (EMS will check there)

   • Keep a copy in your wallet or medical file

   • Attach to a medical bracelet or necklace (optional but helpful)

   • Give copies to caregivers, hospice staff, or facility administrators

3. Do Not Laminate It While you can protect it in a clear sleeve, lamination is discouraged as it may make signatures difficult to verify.

4. Review Regularly Review this form at least once a year or after any major health event. You can revoke or change your DNR status at any time.

🛠️ Need Help?

We can help you:

• Understand if a DNR is right for you

• Talk through this decision with your doctor or care team

• Make sure the form is completed, signed, and filed correctly

You don’t need to figure this out alone.