Order-Do Not Resuscitate


DO-NOT-RESUSCITATE ORDER

I have discussed my health status with my physician,_______________ .

. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me.

This order is effective until it is revoked by me.

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

______________________________________________________________________________

(Declarant’s signature)

______________________________________________________________________________

(Date)

(Type or print declarant’s full name)

______________________________________________________________________________

(Signature of person who signed for declarant, if applicable)

______________________________________________________________________________

(Date)

(Type or print full name)

______________________________________________________________________________

(Physician’s signature)

______________________________________________________________________________

(Date)

(Type or print physician’s full name)

ATTESTATION OF WITNESSES

The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the individual has (has not) received an identification bracelet.

______________________________________________________________________________

(Witness signature)

(Type or print witness’s name)

______________________________________________________________________________

(Date)

______________________________________________________________________________

(Witness signature)

(Type or print witness’s name)

Attorney Specific Forms

–For Attorney Specific Forms you can download in Word format, go to

http://www.uslegalforms.com/forattorneys/

______________________________________________________________________________

(Date)