Form Doc 140138c - Do Not Resuscitate Consent - Oklahoma Department Of Corrections printable pdf download

Form Doc 140138c - Do Not Resuscitate Consent - Oklahoma Department Of Corrections

OKLAHOMA DEPARTMENT OF CORRECTIONS

Do Not Resuscitate Consent Form

I, ________________________________________________ DOC #____________________,

request limited health care as described in this document. If my heart stops beating, or if I stop

breathing, no medical procedure to restore breathing or heart function will be instituted by any

health care provider, including but not limited to emergency medical services (EMS) personnel.

I understand that this decision will not prevent me from receiving other health care such as the

Heimlich maneuver or oxygen and other comfort care measures.

I understand that I may revoke this consent at any time, in writing or by telling the physician or

other health care provider or witness, regardless of my physical or mental condition.

I give permission for this information to be given to EMS personnel, doctors, nurses, and other

health care providers. I hereby state that I am making an informed decision and agree to a Do

Not Resuscitate Order.

_______________________________________________

_____________

Signature of Patient

Date

_______________________________________________________

________________

Signature of Health Care Proxy-Acting under the Oklahoma Advance

Date

Directive Act and the Oklahoma Do-Not Resuscitate Act

This DNR form was signed in my presence.

____________________________________

___________

Signature of Witness

Date

___________________________________________________________

Address:

____________________________________

___________

Signature of Witness

Date

___________________________________________________________

Address:

DOC 140138C (R 11/14)

Form Doc 140138c - Do Not Resuscitate Consent - Oklahoma Department Of Corrections