Pre-Hospital Do Not Resuscitate (Dnr) Form (Page 2 of 2) in pdf

Pre-Hospital Do Not Resuscitate (Dnr) Form Page 2

****The Patient MUST send or deliver this original form to the****

Williston Ambulance Service, P.O. Box 2169, 317-11th St West, Williston, ND 58802-2169

This Form will not be accepted if it has been amended or altered in any way.

WILLISTON AMBULANCE SERVICE APPROVAL

This form is APPROVED / NOT APPROVED. If not approved, return form to patient with note as to why it has not

been approved and retained a copy of such DNR and note saying why it is not approved. If approved, forward the form

to 911 Service.

This form has been reviewed and ACCEPTED / NOT ACCEPTED by

_______________________________ on ________________

(Williston Ambulance Employee)

(Date)

911 RECORDING INFORMATION

I, ______________________________(Please Print Name), received this form on this ________ day of

__________________, 20_____.

I, ____________________________(Printed Name), have put the above DNR information in the file for the above

person and Social Security number listed in the DNR on this ___________ day of ____________________, 20_______,

and sent the copies by regular mail to the following:

Pre-Hospital DNR Request Form

One copy:

To patient ___________ (Initial)

One copy:

To doctor ____________(Initial)

Pre-Hospital Do Not Resuscitate (Dnr) Form Page 2