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APPLICATION - ADULT
(Please Print or Type)
Gender □M □F Date of Birth _____/_____/_____
Address City __________________ State _____ ZIP______ Phone _______________
A. Patient’s Statement
I, the above named patient, am capable of making an informed decision and do not wish to receive life-resuscitating
treatment in the event of a cardiac or respiratory arrest. Therefore, I direct Emergency Medical Services
personnel to withhold life-resuscitating treatment. I state that I have informed each member of my family within the
first degree of consanguinity or affinity, whose whereabouts are known to me, or if no such members are living, my
legal guardian, if any, or if I have no such member living and have no legal guardian, my caretaker, if any, of my
decision to apply for a Do-Not-Resuscitate identification.
SS# Date _____/_____/_____
B. Agent’s Statement
I am the above named patient’s agent (with durable power of attorney for healthcare). The patient does not wish to
receive life-resuscitating treatment in the event of a cardiac or respiratory arrest. I direct Emergency Medical Services
personnel to withhold life-resuscitating treatment in the event of a cardiac or respiratory arrest.
Agent Name and Address (print)
Phone Date ____/_____/_____
Attending Physician’s Statement
As required by Nevada Revised Statutes (NRS) 450B.520(2), I certify that I am the above named patient’s attending
physician/physician who has primary responsibility for the treatment and care of the patient and that the patient suffers
from a terminal condition. The patient is capable of making an informed decision or, when he was capable of making an
informed decision, he executed a written directive that life-resuscitating treatment be withheld under certain
circumstances, or a durable power of attorney for health care decisions pursuant to NRS 449.800 to 449.860, inclusive,
or he was issued a Do-Not-Resuscitate Order pursuant to NRS 450B.510.
Attending physician’s name (print):
Attending physician’s signature:
Office Use Only:
Received: __________ Issued: __________ By: __________ DNR ID # __________
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