Free Do Not Resuscitate Order Form for New York

New York Do Not Resuscitate Order

This Do Not Resuscitate (DNR) Order is issued in accordance with New York State Public Health Law Section 2994-b. This document indicates that in the event of cardiac or respiratory arrest, the individual does not wish to receive resuscitation.

Patient Information:

• Name: ____________________________
• Date of Birth: _____________________
• Address: __________________________
• City, State, Zip: ________________

Authorized Representative Information (if applicable):

• Name: ____________________________
• Relationship to Patient: ______________
• Signature: ___________________________
• Date: _______________________________

Medical Decision-Maker Information (if different from above):

• Name: ____________________________
• Relationship to Patient: ______________
• Signature: ___________________________
• Date: _______________________________

Statement of Wishes:

I, the undersigned, request that resuscitative efforts not be initiated in the event of cardiac or respiratory arrest. This decision is made after consideration of my current medical condition and prognosis.

Patient or Authorized Representative Signature:

• Signature: ___________________________
• Date: _______________________________

Witness Information:

• Name: ____________________________
• Signature: ___________________________
• Date: _______________________________

Healthcare Provider Signature:

• Name: ____________________________
• Title: ______________________________
• Signature: ___________________________
• Date: _______________________________

This DNR Order is valid until revoked or replaced. A copy of this order should be placed in the patient's medical record and given to the patient or authorized representative.