Florida Do Not Resuscitate Order Template
This Do Not Resuscitate (DNR) Order is in accordance with Florida state law (Chapter 401.45, Florida Statutes). Please complete the sections below to ensure your wishes are documented clearly.
Patient Information:
- Patient Name: _____________________________
- Date of Birth: _____________________________
- Address: _____________________________
- City, State, Zip Code: _____________________________
Health Care Proxy Information:
- Name: _____________________________
- Relationship: _____________________________
- Phone Number: _____________________________
DNR Order Statement:
In accordance with my wishes regarding medical treatment, I do not wish to receive cardiopulmonary resuscitation (CPR) or advanced cardiac life support if I suffer a cardiac or respiratory arrest.
Signature and Consent:
By signing below, I confirm that this DNR order reflects my wishes regarding resuscitation efforts. I authorize the healthcare professionals to follow this order in case of an emergency.
Signature of Patient: _____________________________
Date: _____________________________
Witness Information:
- Name: _____________________________
- Signature: _____________________________
- Date: _____________________________
This document should be kept in a prominent location and shared with your healthcare providers to ensure your wishes are known.
