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Alaska Do Not Resuscitate (DNR) Order Form – Sample Only

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The Alaska do not resuscitate (DNR) order form is to be primarily used by individuals who are in the late stages of a terminal disease and do not want to be brought back to life if they die. The form may only be obtained from a licensed physician practicing in the State of Alaska. The patient can contact their doctor and, if approved, will have the form signed and sent to them.

If you’re a licensed physician you can obtain the forms by calling your respective region’s Comfort One Office:

  • Southern Region EMS Council, Anchorage – (907) 562-6449
  • Interior Region EMS Council, Fairbanks – (907) 456-3978
  • Southeast Region EMS Council, Sitka – (907) 747-8005

Comfort One Program – This is the official office that handles do-not-resuscitate forms in Alaska. If you are a patient that has been approved, you can also get a wallet card and a bracelet in case you cannot speak for yourself while receiving care.

Laws – AS 13.52.150

Required to Sign – Patient and physician.

How to Write

Step 1 – This is a sample form but will instruct how to complete the form. Download in Adobe PDF.

Step 2 – The first section of the form is the ‘Patient Information’ section. Enter the patient’s name, date of birth, address and gender into the appropriate fields.

Step 3 – The next two spaces are the ‘Patient Signature’ and ‘Date’. The patient must inscribe their signature and include the date upon which the form was signed.

Step 4 – The physician is also required to sign off on the DNR Form, confirming that everything meets the appropriate medical qualifications. Aside from their signature, the physician must also include their printed name, phone number and the current date.

Step 5 – Under ‘Additional Information’, the patient’s illness or condition must be written out in the provided field. Next, select “Yes” or “No” in regards to whether or not the patient has a pacemaker.


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