Ohio Do Not Resuscitate Order Template
This Do Not Resuscitate (DNR) Order is created in accordance with Ohio state laws for individuals who wish to refuse resuscitation in the event of a medical emergency.
Patient Information:
- Patient Full Name: ________________________________
- Patient Date of Birth: _____________________________
- Patient Address: __________________________________
- Patient Phone Number: ____________________________
Physician Information:
- Physician Full Name: _____________________________
- Physician Phone Number: _________________________
- Physician License Number: ________________________
Patient Statement:
I, the undersigned, hereby declare that I do not want resuscitative measures used to prolong my life in the event of cardiac or respiratory arrest.
Signature: ______________________________________
Date: _________________________________________
This order is effective immediately upon signing and shall remain in effect until revoked by the patient.
Witness Statements:
Witness 1 Name: _____________________________________
Witness 1 Signature: _________________________________
Witness 1 Date: _____________________________________
Witness 2 Name: _____________________________________
Witness 2 Signature: _________________________________
Witness 2 Date: _____________________________________
Please keep a copy of this DNR Order in a prominent place and provide copies to your physician and family members.
