Florida Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is created in accordance with the laws of the state of Florida. It reflects the patient's wishes regarding resuscitation efforts in the event of a medical emergency.
Patient Information:
- Name: ___________________________
- Date of Birth: ____________________
- Address: _________________________
- City, State, Zip Code: ____________
Physician Information:
- Physician Name: ___________________
- Medical License Number: ___________
- Phone Number: _____________________
Patient's Wishes:
The patient, named above, has expressed a desire to forgo cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. This decision was made after thorough discussions regarding the potential outcomes and consequences of resuscitation.
Witness Information:
- Witness Name: _____________________
- Date: ____________________________
Signature:
I, the undersigned patient or legal representative, confirm that this DNR Order reflects my wishes.
_______________________
Date: __________________
By signing below, the physician acknowledges the patient's wishes and agrees to honor this DNR Order.
_______________________
Physician Signature
Date: __________________
This document should be kept in a place easily accessible to medical personnel. Copies of this DNR Order should be provided to the patient's family and any healthcare facility where the patient receives care.