Oklahoma Do-Not-Resuscitate (Dnr) Consent Form printable pdf download

OKLAHOMA DO-NOT-RESUSCITATE (DNR) CONSENT FORM

I, __________________________, 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 one of the following ways:

1. If I am under the care of a health care agency, by making an oral, written, or other act of

communication to a physician or other health care provider of a health care agency;

2. If I am not under the care of a health care agency, by destroying my do-not-resuscitate form,

removing all do-not-resuscitate identification from my person, and notifying my attending

physician of the revocation;

3. If I am incapacitated and under the care of a health care agency, my representative may

revoke the do-not-resuscitate consent by written notification of a physician or other health

care provider of the health care agency or by oral notification of my attending physician; or

4. If I am incapacitated and not under the care of a health care agency, my representative may

revoke the do-not-resuscitate consent by destroying the do-not-resuscitate form, removing all

do-not-resuscitate identification from my person, and notifying my attending physician of the

revocation.

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.

__________________________OR_____________________________________

Signature of Person Signature of Representative

(Limited to an attorney-in-fact for health care decisions acting under the Durable Power of

Attorney Act, a health care proxy acting under the Oklahoma Rights of the Terminally III or

Persistently Unconscious Act or a guardian of the person appointed under the Oklahoma

Guardianship and Conservatorship Act.)

This DNR consent form was signed in my presence.

__________________________

___________________________

_____________________

Date

Signature of Witness

Address

____________________________

_____________________

Signature of Witness

Address

Oklahoma Do-Not-Resuscitate (Dnr) Consent Form