Florida Do Not Resuscitate (DNR) Order Form

Create a high quality document online now!

Updated May 31, 2022

A Florida do not resuscitate order form (DNR or DNRO) is a document that is used by residents of Florida who suffer from incurable or irreversible medical conditions. This form states that the requester does not wish to be resuscitated in the event of respiratory or cardiac arrest. Although not always reserved for patients with terminal illnesses, it is the most common reason for a physician to sign off on a DNR order. A DNR must be honored in any health care setting by all medical personnel, including EMTs and paramedics outside of a medical facility. For a Florida DNR to be legally valid, the form must be printed on yellow paper before it is filled out by the patient/authorized representative and physician.

LawsFAC 64J-2.018

Required to Sign – Patient and physician.

How to Write

Download: Adobe PDF

Step 1 – Access The Florida Do Not Resuscitate (DNR) Order Form As An Adobe PDF File

The Florida Do Not Resuscitate Order Form is a downloadable “PDF” template through this site. The button in the caption area of the displayed sample image or the link in this section enables this download.

Step 2 – Identify The Florida Resident Issuing This Paperwork

Once you have opened this form, locate the two blank lines at the top of the page. The first of these blank lines, labeled “Patient’s Full Legal Name,” requires the complete name of the Patient who does not wish Medical Personnel to intervene with a resuscitation when this is necessary to prolong life. In addition to the Patient’s name, the current calendar “Date” must be set to display on the adjacent blank line. 

 

Step 3 – Indicate If The Issuer Will Provide The Executing Signature Personally

The multiple-choice area provided after the “Patient’s Statement” can be considered a necessity. In some cases, the Patient issuing this document may not be conscious but has previously set a directive that instructs his or her Health Care Representative to set this document in motion. If so, then the role this Party fills must be defined. Thus, one of these checkboxes must be marked if this paperwork is being issued by an Agent representing the Patient (with the Patient’s consent). If this Agent is a “Surrogate” then mark the first checkbox (on the left) below the words “If Not Signed By Patient, Check Applicable Box.”If the Representative is a “Court Appointed Guardian” then indicate this by selecting the second checkbox item. At times, some paperwork may be lacking but a general understanding that a decision by “Proxy” can be made by a specific adult (i.e. the Patient’s Parent). If this is the Party issuing this order, then mark the first checkbox on the right.  If the Individual issuing this paperwork on behalf of the Patient, is the Attorney-in-Fact for the Patient (or Principal) in a currently active durable power of attorney, then mark the checkbox labeled “Durable Power Of Attorney (Pursuant To Chapter 709, F.S.)”  

 

Step 4 – Execute The Florida Order By Signature

This document must be signed by the Patient issuing it or the appropriate Patient Agent/Representative. Thus, when it is time to issue this document, the Patient or an appropriate Representative of the Patient must locate the blank line labeled “Applicable Signature.” He or she must sign this line then print this or her name in the area labeled “Print Or Type Name.”   

 

Step 5 – Obtain The Physician Approval For This Issuance

The next section of this issue is the “Physician’s Statement” section. This area is mandatory and must be completed by the Patient’s Physician. He or she must read the paragraph beginning with the term “I, The Undersigned, A Physician Licensed Pursuant to Chapter 458 Or 459, F.S…” then agree to this statement by signing his or her name on the “Signature Of Physician” area of the blank line provided. The second and third areas of this line are labeled to accept the Physician’s signature “Date” and “Telephone Number (Emergency).”   The Physician must also print his or her name where requested then supply his or her “Physician’s Medical License Number.”

 

Step 6 – Acquire The Portable Physician Approval

Naturally, this form may need to be carried physically on the body of the Patient (recommended). Since a standard 8 1/2 in by 10-inch sheet of paper can be unwieldy in day-to-day life a portable DNR has been supplied. This means that a portable “Physician’s Statement” must be completed (by the Physician). Locate the second “Physician’s Statement” section on the left below the perforation then check to make sure the Physician has signed the “Signature Of Physician” line to testify to the accuracy of the above statement, produced the “Date” of this signature, and presented his or her “Telephone Number (Emergency)” to the areas of the line where each is requested.  Next, the Signature Physician should have printed his or her full name on the “Print Or Type Name” line underneath the signature line as well as submit the “Physician’s Medical License Number” that enables him or her to practice medicine in the State of Florida. 

 

Step 7 – Reproduce Your Name In The Portable DNR

The portable DNR can also be found under the perforation but should be sought out on the right side of the page. The first requirement presented by this area of the document is for the full name of the Patient to be produced for display on the line labeled “Patient’s Full Legal Name (Print Or Type)” and the “Date” when this document is being completed.   

 

Step 8 – If Needed, Continue The Portable DNR With The Signature Party’s Role

If the Patient is not the Signature Party putting this document in effect, then the role of the Signature Party in the Patient’s life must be established. A series of multiple-choice descriptions should be reviewed so that the nature of the Signature party can be defined. If he or she is a “Surrogate” then mark the first checkbox.  A signature by “Proxy” to this issuance should be documented by selecting the next checkbox to choose from.   Mark the third checkbox if the Signature Party is a “Court Appointed Guardian.”  If the signature is being supplied by an Attorney-in-Fact named in the Patient’s durable power of attorney, then select the fourth checkbox (labeled “Durable Power Of Attorney” 

 

Step 9 – Produce The Executing Signature For the Portable DNR

The Florida DNR must be put in effect by Patient Signature if it is to be taken seriously. As mentioned earlier, if the Patient is unable to communicate but has instructed another Party to issue this (on the Patient’s behalf) then this Agent must sign this document. The “Applicable Signature” line at the bottom of the portable DNR expects this signature and the full printed name of the Signature Party (Patient) provided to the labeled area provided.