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Get dhec 3462 2015-2024

Cluding artificial stimulation of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardiopulmonary arrest. REVOCATION PROCEDURE THIS FORM MAY BE REVOKED BY AN ORAL STATEMENT BY THE PATIENT TO EMS PERSONNEL, OR BY MUTILATING, OBLITERATING, OR DESTROYING THE DOCUMENT IN ANY MANNER. Date Patient's Signature (or Surrogate or Agent) Physician's Name (Please Print) Physician's Signature Physician's Address Physician's Telephone Num.

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