California Do Not Resuscitate Order (DNR)
This Do Not Resuscitate Order (DNR) is created in accordance with California Health and Safety Code Sections 7180-7183. It expresses the wishes of the individual regarding resuscitation efforts in the event of cardiac arrest or respiratory failure.
Please fill out the information below:
- Patient Name: ___________________________________
- Date of Birth: ___________________________________
- Primary Physician: ___________________________________
- Physician's Contact Number: ______________________
- Emergency Contact Name: __________________________
- Emergency Contact Number: ______________________
The patient, named above, requests that in the event of a medical emergency resulting in cardiac arrest or respiratory failure, no efforts be made to revive or resuscitate them. This request is based on the patient’s stated values and medical conditions.
This order is valid and in effect until:
- Effective Date: ___________________________________
- Expiration Date (if any): ________________________
Signature of Patient or Legal Representative: _____________________
Date: ______________________________________________________
Signature of Witness: ________________________________________
Date: ______________________________________________________
This DNR may be revoked at any time by verbally stating the desire to revoke.
Please keep copies of this document in accessible locations and provide a copy to your primary physician.
