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California Do Not Resuscitate Form

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California Do Not Resuscitate Form Page 2
California Do Not Resuscitate Form
CMA PUBLICATIONS 1(800) 882-1262 WWW.CMANET.ORG
EMERGENCY MEDICAL SERVICES
PREHOSPITAL DO NOT RESUSCITATE (DNR) FORM
An Advance Request to Limit the Scope of Emergency Medical Care
I, _________________________________________, request limited emergency care as herein described.
(print patient’s name)
I understand DNR means that if my heart stops beating or if I stop breathing, no medical procedure to restart
breathing or heart functioning will be instituted.
I understand this decision will not prevent me from obtaining other emergency medical care by prehospital
emergency medical care personnel and/or medical care directed by a physician prior to my death.
I understand I may revoke this directive at any time by destroying this form and removing any “DNR” medallions.
I give permission for this information to be given to the prehospital emergency care personnel, doctors, nurses or
other health personnel as necessary to implement this directive.
I hereby agree to the “Do Not Resuscitate” (DNR) order.
Patient/Legally Recognized Health Care Decisionmaker Signature Date
Legally Recognized Health Care Decisionmaker’s Relationship to Patient
By signing this form, the legally recognized health care decisionmaker acknowledges that this request to forego resuscitative measures is consistent with
the known desires of, and with the best interest of, the individual who is the subject of the form.
I affirm that this patient/legally recognized health care decisionmaker is making an informed decision and that this
directive is the expressed wish of the patient/legally recognized health care decisionmaker. A copy of this form is
in the patient’s permanent medical record.
In the event of cardiac or respiratory arrest, no chest compressions, assisted ventilations, intubation, defibrillation,
or cardiotonic medications are to be initiated.
Physician Signature Date
Print Name Telephone
THIS FORM WILL NOT BE ACCEPTED IF IT HAS BEEN AMENDED OR ALTERED IN ANY WAY
PREHOSPITAL DNR REQUEST FORM
White Copy:
To be kept by patient
Yellow
Copy:
To be kept in patient’s permanent medical record
Pink Copy:
If authorized DNR medallion desired, submit this form with Medic Alert enrollment form to: Medic Alert Foundation, Turlock, CA 95381
California Do Not Resuscitate Form
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