Free Do Not Resuscitate Order Form for Texas

Texas Do Not Resuscitate (DNR) Order Template

This Do Not Resuscitate (DNR) order is created in accordance with the Texas Health and Safety Code, Chapter 166. This document is intended to communicate a patient's wishes regarding resuscitation efforts in the event of cardiac or respiratory arrest.

Patient Information:

• Patient's Full Name: ______________________
• Date of Birth: ___________________________
• Patient's Address: ________________________
• City, State, Zip Code: ___________________
• Patient's Medical Record Number: __________

Health Care Provider Information:

• Health Care Provider's Name: ______________
• Provider's Contact Number: ________________
• Facility Name: ____________________________
• Facility Address: _________________________

Patient's Wishes:

I, the undersigned, hereby declare my wishes regarding resuscitation. In the event of cardiac or respiratory arrest, I do not wish to receive the following treatments:

• Cardiopulmonary resuscitation (CPR)
• Defibrillation
• Advanced airway management

This order is to be followed unless I revoke it in writing or verbally communicate my desire to rescind it to my medical team.

Signatures:

Patient's Signature: ________________________ Date: _____________

Health Care Provider's Signature: ___________ Date: _____________

Witness Information (optional):

• Witness Name: ____________________________
• Witness Signature: ________________________
• Date: _____________________________________

Keep this document with your health care directive and ensure that copies are provided to your medical team and family members. This DNR order will be honored by medical personnel in the state of Texas.