Georgia Do Not Resuscitate Order (DNR)
This Do Not Resuscitate (DNR) Order is prepared in accordance with the Georgia Advance Directive for Health Care statutes (O.C.G.A. § 31-32-1 et seq.). This document applies to individuals who wish to refuse resuscitation under specific circumstances outlined herein. Please fill in the sections below accurately and clearly.
Patient Information
- Patient's Name: ________________________________
- Date of Birth: ________________________________
- Address: ________________________________
Patient's Wishes Regarding Resuscitation
Please indicate your wishes regarding resuscitation:
- I, the above-named patient, do NOT want resuscitation, including but not limited to the following:
- Cardiopulmonary Resuscitation (CPR)
- Advanced Cardiac Life Support (ACLS)
Signature of Patient or Legal Representative
This form must be signed by the patient or their legal representative:
- Signature: ________________________________
- Date: ________________________________
Witness Information
The following should witness the signing of this document:
- Witness Name: ________________________________
- Witness Signature: ________________________________
- Date: ________________________________
This DNR Order is valid if it contains the patient’s signature and is in compliance with Georgia law. Please distribute copies to your healthcare providers and keep the original in a safe place.