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Ohio Do Not Resuscitate Form

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

Ohio Do Not Resuscitate Form
Ohio Do Not Resuscitate Form
(If this box is checked the DNR Comfort Care Protocol is activated immediately.)
(If this box is checked, the DNR Comfort Care Protocol is implemented in the event of a
cardiac arrest or a respiratory arrest.)
Patient Name:_____________________________________________________________________________________
City____________________________________________________ State_______________ Zip___________________
Birthdate____________________________ Gender M F
Signature_____________________________________________________ (optional)
Certification of DNR Comfort Care Status (to be completed by the physician)*
(Check only one box)
Do-Not-Resuscitate Order—My signature below constitutes and confirms a formal order to emergency
medical services and other health care personnel that the person identified above is to be treated under the
State of Ohio DNR Protocol. I affirm that this order is not contrary to reasonable medical standards or, to the
best of my knowledge, contrary to the wishes of the person or of another person who is lawfully authorized to
make informed medical decisions on the person’s behalf. I also affirm that I have documented the grounds for
this order in the person's medical record.
Living Will (Declaration) and Qualifying Condition—The person identified above has a valid Ohio
Living will (declaration) and has been certified by two physicians in accordance with Ohio law as being
terminal or in a permanent unconscious state, or both.
Printed name of physician*:_________________________________________________________________________
Signature_______________________________________________ Date___________________________________
Address:_______________________________________________ Phone_________________________________
City/State______________________________________________ Zip___________________________________
* A DNR order may be issued by a certified nurse practitioner or clinical nurse specialist when authorized by section
2133.211 of the Ohio Revised Code.
See reverse side for DNR Protocol
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Ohio Do Not Resuscitate Form