DO NOT RESUSCITATE FORM
(
DNR) Order Template

A "do not resuscitate order", is a form document written for patients to inform medical workers not to perform CPR or ACLS if patient’s breath or heartbeat stops. Also referred as a No Code or DNR order.

Make sure the form complies with the rulers and regulations of your state. Some states require a photo to be attached to the form, others reqquire this form must be printed on yellow paper prior to being completed to be legally valid. EMS and medical personnel are only required to honor the form if it is printed on yellow paper.

Before using any legal document you must consult a licensed lawyer who will make sure this, or any other form you find on the internet will fit to your needs and is valid to be used in your state of residence.

Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, D.C., Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming.


DO NOT RESUSCITATE ORDER


PATIENT INFORMATION: 

Name ___________________________________   Gender: Male□ Female□  

Date of Birth ___/___/_____  Race _________ Eye Color __________________ 

Hair Color ________ Address ___________________________________________   

City __________________ State _____ ZIP______ Phone _______________


I, the above named patient, am capable of making an informed decision and do not wish to receive life-resuscitating treatment in the event of a cardiac or respiratory arrest.

I understand “Do Not Resuscitate” (DNR) order means that if my heart stops beating or if I stop breathing, no medical procedure to restart breathing or heart functioning will be instituted.  

I give permission for this information to be given to the prehospital emergency care personnel, doctors, nurses or other health personnel as necessary to implement this directive. 

I understand I may revoke this directive at any time by destroying this form and removing any “DNR” medallions.  

I hereby agree to the “Do Not Resuscitate” (DNR) order.


__________________________________________________               ___/___/______

Patient’s Legally Recognized Health Care Decisionmaker Signature         Date

PHYSICIAN’S STATEMENT

I, the undersigned, a physician licensed number _____________________, am the physician of the patient named above. I hereby understand that in the event of cardiac or respiratory arrest, NO cardiopulmonary resuscitation, chest compressions, assisted ventilations, intubation, defibrillation, cardiotonic medications, advanced cardiac life support drugs, and related medical procedures are to be initiated.

I have explained this form and its consequences to the signer and obtained assurance that the signer understands that death may result from any refused care listed above

I also understand that consent for the order for resuscitation may be revoked at any time by the consenting person.

_________________________________            ____________________________ 

Physician Signature                                               Print Name   

License Number ____________________

Telephone Number __________________ 

Date ___/___/______


WITNESS

I  was present when this was signed (or marked). The patient then appeared to be of sound mind and free from duress.   

_____________________________________ Date ____/____/_____  

Witness Signature


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Do Not Resuscitate Form
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