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North Dakota Do Not Resuscitate Form

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North Dakota Do Not Resuscitate Form
DNR Form
City of Williston - Emergency Medical Services
Pre-Hospital Do Not Resuscitate (DNR) Form
An Advance Request to Limit the Scope of Emergency Medical Care
I, _______________________________________, of____________________________________________________,
(Print Patient’s name (required)) (Street, City, State, ZIP)
request limited emergency care as herein described. My telephone number is (_ _ _) _ _ _-_ _ _ _ My Social Security
Number is_ _ _/_ _/_ _ _ _ and my date of birth is ___________________(required).
Sex (please circle one): Male Female
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 pre-hospital 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, notifying Williston Ambulance Service in
writing, and removing my “DNR” medallions.
I give my permission for this information to be given to the pre-hospital 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.
I also understand that the Ambulance may have been called and there are situations in which conflicting directives may
be given by family and others resulting in attempts being made to resuscitate me. In consideration of utilizing this DNR
request I, on behalf of myself and my heirs release any claim for damages resulting from such attempted resuscitation I
may have against any emergency response personnel, the Williston Ambulance Service, the City of Williston, and the
911 system.
_______________________________________________ _______________
Patient/Surrogate Signature Date
Surrogate’s Relationship to Patient
Please attach original or certified copy of medical power of attorney or court order appointing surrogate (required if
surrogate signs)
Subscribed and sworn before me this __________ day of ___________, 20_______
(SEAL) ______________________________
Notary Public
My Commission Expires:
I affirm that this patient/surrogate is making an informed decision that this directive is the expressed wish of the patient/
surrogate. 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, intubations, defibrillation, or
cardiotonic medications are to be initiated.
_________________________________________ ______________________
Physician Signature Date
Physician’s Address (required): ______________________________________________
(City, State, Zip)
North Dakota Do Not Resuscitate Form