Updated July 18, 2023
The Arizona do not resuscitate (DNR) order form is for any individual who do not wish to be brought back to life in the event they stop breathing, or if a medical professional notices a lack of cerebral activity. Resuscitation includes, but is not limited to, CPR, cardiac compressions, defibrillation, and artificial ventilation. Although anyone can potentially request a DNR form through their physician, this form is generally reserved for those to whom resuscitation would do more damage than good; i.e., terminally ill or very sick/weak patients. The form used below is a sample form.
Laws – § 36-3251
Format – Arizona law states that a valid DNR must be on letter or wallet-sized paper, and printed on an orange background.
Required to Sign – Patient, licensed physician, and a witness.
How to Write
Step 1 – Download in PDF (must be on paper with an orange background to be valid).
Step 2 – Under section ‘1.’, the patient must sign on the proper line, and include their printed name and the date.
Step 3 – Next, the following patient information must be provided in the appropriate fields:
- Date of birth
- Sex
- Race
- Eye color
- Hair color
Alternatively, a photograph of the patient can be attached on the right of the fields mentioned above.
Step 4 – The name of the patient’s physician must be provided along with their phone number and hospice program name (if applicable).
Step 5 – A Licensed Health Care Provider must sign and date the fields under section ‘3’.
Step 6 – A notary public or adult witness must be present when the DNR form is signed. The witness cannot be under the age of eighteen (18), related to the patient, entitled to a portion of the patient’s estate, appointed as the patient’s representative or involved in providing health care to the patient. The notary/witness must sign and date the bottom of the form after witnessing all the signatures.
