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Arkansas Do Not Resuscitate (DNR) Order Form

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The Arkansas do not resuscitate (DNR) order form is a document requested by an individual who does not wish to receive any resuscitation procedures in the event of a medical emergency. Typically, a DNR is ordered by people who are terminally ill, or who are against receiving life-prolonging treatment when close to death. When submitted to a hospital, an individual can request this form through their physician. Alternatively, one could ask their physician ahead of time for a DNR form, which would alert emergency responders/personnel, paramedics, etc. of the individual’s wishes. Medical procedures such as cardiopulmonary resuscitationĀ (CPR) and advanced cardiac life support (ACLS) will be avoided as long as a person has a DNR bracelet, anklet, necklace or another such indicator on their person.

LawsĀ§ 20-13

Required to Sign – Patient and physician.

How to Write

Step 1 – Download the Arkansas DNR Form in Adobe PDF.

Step 2 – Enter the patient’s full name. The patient, or their health care proxy or legal guardian, must sign on the line below the patient’s printed name. Enter the current date next to the signature.

Step 3 – The patient’s physician must approve of the do not resuscitate order, and therefore must sign the form on the appropriate line. The physician must include their phone number, printed name, and date that the order was inscribed.


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