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Oklahoma Do Not Resuscitate Form


Oklahoma Do Not Resuscitate Form
Oklahoma Do Not Resuscitate Form
OKLAHOMA DO-NOT-RESUSCITATE (DNR) CONSENT FORM
I, , request limited health care as
described in this document. If my heart stops beating or if I stop breathing, no
medical procedure to restore breathing or heart function will be instituted by any
health care provider including, but not limited to, emergency medical services
(EMS) personnel.
I understand that this decision will not prevent me from receiving other health
care such as the Heimlich maneuver or oxygen and other comfort care measures.
I understand that I may revoke this consent at any time in one of the
following ways:
1. If I am under the care of a health care agency, by making
physicianatoioncommunicatofactother
orwritten,oral,an
or other health care provider of a
health care agency;
2. If I am not under the care of a health care agency, by
do-not-resuscitateallremovingform,resuscitate
do-not-mydestroying
identification from my person,
and notifying my attending physician of the revocation;
3. If I am incapacitated and under the care of a health care agency, my
representative may revoke the do-not-resuscitate consent by written notification
to a physician or other health care provider of the health care agency or by oral
notification to my attending physician; or
4. If I am incapacitated and not under the care of a health care
byconsentedo-not-resuscitattherevokemayrepresentative
my,yagenc
destroying the
do-not-resuscitate form, removing all do-not-resuscitate identification from my
person, and notifying my attending physician of the revocation.
I give permission for this information to be given to EMS personnel, doctors,
nurses, and other health care providers. I hereby state that I am making an
informed decision and agree to a do-not-resuscitate order.
Signature of Person
or
Signature of Representative
(Limited to an attorney-in-fact for health care
decisions acting under the Durable Power of Attorney
Act, a health care proxy acting under the Oklahoma
Advance Directive Act or a guardian of the person
appointed under the Oklahoma Guardianship and
Conservatorship Act.)
This DNR consent form was signed
in my presence.
Date
Signature of Witness
Address
Signature of Witness
Address
Oklahoma Do Not Resuscitate Form
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