At Speedy Template, You can download Tennessee Do Not Resuscitate Form . There are a few ways to find the forms or templates you need. You can choose forms in your state, use search feature to find the related forms. At the end of each page, there is "Download" button for the forms you are looking form if the forms don't display properly on the page, the Word or Excel or PDF files should give you a better reivew of the page.
PH-3338 (Rev. 7-96)RDA N/A
STATE OF TENNESSEE
EMERGENCY MEDICAL SERVICES
DO NOT RESUSCITATE (DNR)
Patient’s Full Name
ATTENDING PHYSICIAN’S STATEMENT
I am the attending physician of the patient named above and direct medical personnel not initiate cardiopulmonary
resuscitation on this patient. I understand that I may revoke these directions at any time.
Datesignature of Attending Physician
PRINTED NAME OF ATTENDING PHYSICIAN
THIS ORDER REMAINS IN EFFECT UNTIL THE DEATH OF THE
PATIENT OR THE DOCUMENT IS DESTROYED
I, the undersigned patient, or agent with a durable power of attorney for health care, direct that cardiopulmonary
resuscitation should not be initiated. I understand that I may revoke these directions at any time.
Signature of WitnessSignature of Patient
Printed Name of WitnessPrinted Full Name of Patient
Printed Full Name of Person Acting with durable
power of attorney for health care
THIS FORM WILL ACCOMPANY THE PATIENT DURING AMBULANCE TRANSPORT
A photostatic copy of the original, properly executed form may serve as a legal DNR order pursuant to Tennessee Code
Annotated § 68-140-602(1)
In the event of the patient’s death, the EMS agency on the scene shall obtain this form and it shall become part of the
EMS Medical Record.
Permission is hereby granted to reprint blank copies of this form for use by patients and physicians. Such copies must
include the complete and original text of both sides of the form with no additions or deletions.
Speedy Template provides all kinds of legal templates, forms and waivers in different editable formats. Use the template search on the top to find the customized templates that fit your needs with absolutely no cost. Those templates are collected online so we do not claim the ownership of those templates. You can think this website as a legal document search portal and use it to find the printable templates and download them to your local computers and make appropriate adjustments from your end. There is no need to create an account or provide your credit card information. Feel free to download those Word, Excel, PowerPoint or PDF files while we continue to improve this website. Hope you can find those free printable templates useful for business or personal purposes.