Fillable Do Not Resuscitate Order Form
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Preview - Do Not Resuscitate Order Form
Do Not Resuscitate Order (DNR) - [State Name]
This Do Not Resuscitate Order (DNR) is made in accordance with the laws of [State Name]. It expresses the individual's wishes regarding resuscitation efforts in the event of cardiac arrest or respiratory failure.
By signing this document, I, [Full Name], residing at [Address], hereby declare my wishes regarding resuscitation efforts, as follows:
- I do not wish to receive cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS) in the event of cardiac arrest.
- I understand that this order may affect my medical care and that it is my responsibility to inform my healthcare providers of my decision.
Please provide the following information at the time of execution of this DNR:
- Patient Name: _____________________________
- Date of Birth: _____________________________
- Healthcare Provider Name: _____________________________
- Healthcare Provider Contact Information: _____________________________
Signatures:
Patient Signature: _____________________________ Date: ___________
Witness Signature: _____________________________ Date: ___________
This order shall remain in effect until revoked. I understand my rights to modify or cancel this DNR Order at any time, and that a copy of this document is as valid as the original.
It is advisable to keep a copy of this order in a location where it can be easily accessed in case of a medical emergency.
Do Not Resuscitate Order - Adapted for Each State
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