NOTICE TO EMS PERSONNEL
This notice is to inform all emergency medical personnel who may be called to render assistance to _________________ that he/she has a terminal condition which has been diagnosed by me, and has specifically requested that no resuscitative efforts including artificial stimulation of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardiopulmonary arrest or, if he/she is a child, such a request has been specifically made by a parent or legal guardian with the legal authority to make medical decisions for the child.
REVOCATION PROCEDURE
THIS FORM MAY BE REVOKED BY AN ORAL STATEMENT BY THE PATIENT OR, IF THE PATIENT IS A CHILD, BY A PARENT OR LEGAL GUARDIAN WITH THE LEGAL AUTHORITY TO MAKE MEDICAL DECISIONS FOR THE CHILD TO EMS PERSONNEL OR BY MUTILATING, OBLITERATING, OR DESTROYING THE DOCUMENT IN ANY MANNER.
Date:_______________________________
___________________________________
Patient's signature (or surrogate or agent)
___________________________________
Parent or Legal Guardian
___________________________________
Physician's signature
___________________________________
Physician's address
___________________________________
Physician's telephone number
S.C. Code § 44-78-30