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Illinois Do Not Resuscitate Form

The Illinois do not resuscitate form is provided by Illinois Department of Public Health.

Illinois Do Not Resuscitate Form
Illinois Do Not Resuscitate Form
State of Illinois
Do Not Resuscitate (DNR) Order
I, ___________________________________ , (print full name)DO NOT AUTHORIZE CARDIOPULMONARY RESUSCITATION.
I (or my legal representative) understand that this order remains in effect until revoked by me (or my legal representative) or
the attending physician. I (or my legal representative) acknowledge that cardiopulmonary resuscitation (CPR) will not be per-
formed if breathing or heart beat stops. (The signatures of [a] the patient ORlegal representative, [b] the physician and
[c] two witnesses are required.)
_________________________________ _________________________________ ______________
Printed name of patient Signature of patient Date
_________________________________ _________________________________ ______________
Printed name of physician Signature of physician Date
_________________________________
Effective date
Legal Representativeî‚’s Signature of Consent for Patient Lacking Decision Making Capacity
(If the patient lacks decision making capacity, then a signature in this section is required.)
___________________________________________ __________________________________________
Printed name of (circle appropriate title) legal guardian Street Address
ORdurable power of attorney for health care agent
ORsurrogate decision maker __________________________________________
City, State, ZIP
___________________________________________
Signature of legal representative
___________________________________________
Date
______________________________ _________________________________ ______________
Printed name of witness Signature of witness Date
______________________________________________________________________________________
Address of witness
______________________________ _________________________________ ______________
Printed name of witness Signature of witness Date
______________________________________________________________________________________
Address of witness
Illinois Department of Public Health
535 W. Jefferson St.
Springfield, IL 62761
217-785-2080,
TTY (hearing impaired use only)
800-547-0466
Reproduce on brightly colored orange paper
Illinois Do Not Resuscitate Form