Do Not Resuscitate Order printable pdf download

Do Not Resuscitate Order

DO-NOT-RESUSCITATE ORDER

This do-not-resuscitate order is issued by ______________________________,

(Type or print physician's name)

attending physician for _______________________________________.

(Type or print declarant’s or ward’s name)

Use the appropriate consent section below, A. or B. or C.

A. DECLARANT CONSENT

I have discussed my health status with my physician named above. I request that

in the event my heart and breathing should stop, no person shall attempt to

resuscitate me.

This order will remain in effect until it is revoked as provided by law.

Being of sound mind, I voluntarily execute this order, and I understand its full

import.

________________________________________ _______________________

(Declarant’s signature)

(Date)

_______________________________________

_______________________

(Signature of person who signed for declarant,

(Date)

if applicable)

_____________________________________

(Type or print full name)

Do Not Resuscitate Order