(A)A document purporting to be a "do not resuscitate order" for EMS purposes must be in substantially the following form: 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
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(A) A document purporting to be a "do not resuscitate order" for EMS purposes must be in substantially the following form: 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 (B) The department may approve a "do not resuscitate bracelet" developed and distributed by a commercial vendor if the bracelet contains an emblem that displays an internationally recognized medical symbol on the front and the words "South Carolina Do Not Resuscitate EMS" and the patient's first name and last name on the back. The department may not approve a "do not resuscitate bracelet" developed and distributed by a commercial vendor if the vendor does not require a health care provider's order for the bracelet before distributing it to a patient. (C) The cost of obtaining a bracelet must be borne by the patient or, if the patient is a child, the parent or legal guardian of the child and may not be provided by the department at the expense of the department. (D) The vendor approved by the department shall not fulfill a request for a "do not resuscitate bracelet" without receiving a health care provider's order for the bracelet with the request.