Out-Of-Hospital Do Not Resuscitate Form printable pdf download

Out-Of-Hospital Do Not Resuscitate Form

DO NOT RESUSCITATE

ALL FIRST RESPONDERS AND EMERGENCY MEDICAL

SERVICES PERSONNEL ARE AUTHORIZED TO COMPLY

WITH THIS OUT-OF-HOSPITAL DNR ORDER.

This request for no resuscitative attempts in the event of a cardiac and/or respiratory arrest for:

______________________________________,has been ordered by the physician whose signature

PLEASE PRINT NAME

appears below. This order is in compliance with the patient’s/surrogate’s wishes and it has been

determined and documented by the physician below that resuscitation attempts for this patient would be

medically inappropriate.

It is expected that this DNR order shall be honored by all Emergency Medical Services (EMS)

personnel, First Responders, and other healthcare providers who may have contact with this patient

during a medical emergency.

PATIENT/SURROGATE SIGNATURE:________________________________________________________________

PATIENT ADDRESS: ________________________________________________________________

THE ABOVE NAMED PATIENT IS UNDER THE CARE OF:

PHYSICIAN NAME:________________________________________________________________________________

PLEASE PRINT NAME

PHYSICIAN ADDRESS:____________________________________________________________________________

TELEPHONE NUMBER:(

) _________ - ____________

MEDICAL FACILITY AFFILIATION:___________________________________________________________________

PHYSICIAN SIGNATURE:_____________________________________________________DATE:________________

THIS DOCUMENT SHOULD BE PROMINENTLY DISPLAYED

AND READILY AVAILABLE TO EMS PERSONNEL

(see reverse for instructions)

INSTRUCTIONS FOR FIRST RESPONDERS/EMS

Out-Of-Hospital Do Not Resuscitate Form