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The South Carolina do not resuscitate form is provided by South Carolina Emergency Medical Services.
DHEC 3462 (12/2000) SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Emergency Medical Services
Do Not Resuscitate Order
EMERGENCY MEDICAL SERVICES
DO NOT RESUSCITATE ORDER
NOTICE TO EMS PERSONNEL
This notice is to inform all emergency medical personnel who may be called to render assistance to
that he/she has a terminal condition which has been diagnosed by me and has
specically requested that no resuscitative efforts including articial stimulation of the cardiopulmonary system by
electrical, mechanical, or manual means be made in the event of cardiopulmonary arrest.
THIS FORM MAY BE REVOKED BY AN ORAL STATEMENT BY THE PATIENT TO EMS PERSONNEL, OR BY MULTI-
LATING, OBLITERATING, OR DESTROYING THE DOCUMENT IN ANY MANNER.
(Name of Patient)
Date Patient's Signature (or Surrogate or Agent)
Physician's Name (Please Print) Physician's Signature
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