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North Dakota Do Not Resuscitate Form

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North Dakota Do Not Resuscitate Form Page 2
North Dakota Do Not Resuscitate Form
****The Patient MUST send or deliver this original form to the****
Williston Ambulance Service, P.O. Box 2169, 317-11th St West, Williston, ND 58802-2169
This Form will not be accepted if it has been amended or altered in any way.
WILLISTON AMBULANCE SERVICE APPROVAL
This form is APPROVED / NOT APPROVED. If not approved, return form to patient with note as to why it has not
been approved and retained a copy of such DNR and note saying why it is not approved. If approved, forward the form
to 911 Service.
This form has been reviewed and ACCEPTED / NOT ACCEPTED by
_______________________________ on ________________
(Williston Ambulance Employee) (Date)
911 RECORDING INFORMATION
I, ______________________________(Please Print Name), received this form on this ________ day of
__________________, 20_____.
I, ____________________________(Printed Name), have put the above DNR information in the file for the above
person and Social Security number listed in the DNR on this ___________ day of ____________________, 20_______,
and sent the copies by regular mail to the following:
Pre-Hospital DNR Request Form
One copy: To patient ___________ (Initial)
One copy: To doctor ____________(Initial)
North Dakota Do Not Resuscitate Form
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