Patient'S Information Form

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Patient’s or Authorized Agent’s Directive to Withhold
Cardio-Pulmonary Resuscitation (CPR)
is template is consistent with rules adopted by the Colorado State Board of Health at 6 CCR 1015-2
Patient’s Information
Patient’s Name _________________________________________________________________________________________
Name of Agent/Legally Authorized Guardian/Parent of Minor Child ______________________________________
Date of Birth ____ /____ /_____ Gender
Male
Female
Eye Color _________
Hair Color ___________
Race Ethnicity
Asian or Paci c Islander
Black, non-Hispanic
White, non-Hispanic
American Indian or Alaska Native
Hispanic
Other
If Applicable- Name of hospice program/provider _____________________________________________________________
Physician’s Information
Physician’s Name _______________________________________________________________________________________
Physician’s Address ______________________________________________________________________________________
_________________________________
Directive Attestation
Check ONLY the information that applies:
Patient I am over the age of 18 years, of sound mind and acting voluntarily. It is my desire to initiate this directive on my
behalf. I have been advised that as a result of this directive, if my heart or breathing stops or malfunctions, I will not receive
CPR and I may die.
Authorized Agent/Legally Authorized Guardian/Parent of Minor Child I am over the age of 18 years, of sound mind, and
I am legally authorized to act on behalf of the patient named above in the issuance of this directive. I have been advised that as
a result of this directive, if the patient’s heart or breathing stops or malfunctions, the patient will not receive CPR and may die.
Tissue Donation I hereby make an anatomical gi , to be e ective upon my death of:
Any needed tissues
e following tissues
Skin
Cornea
Bone, related tissues and tendons
I hereby direct emergency medical services personnel, health care providers, and any other person to
withhold cardio-pulmonary resuscitation in the event that my/the patient’s heart or breathing stops
or malfunctions. I understand that this directive does not constitute refusal of other medical interven-
tions for my/the patient’s care and comfort. If I/the patient am/is admitted to a healthcare facility,
this directive shall be implemented as a physician’s order, pending further physician’s orders.
_______________________________________________
_______________________________________________
Signature of Patient
Physician Signature
Authorized Agent/Legally Authorized Guardian/Parent of Minor Child
_______________________________________________
_______________________________________________
Date
Date

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