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Indiana Do Not Resuscitate (DNR) Order Form

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The Indiana do not resuscitate (DNR) order form is a document used by qualified individuals to state their decision not to be resuscitated should they go into cardiac or respiratory arrest. Qualified individuals include those who have a terminal illness or medical condition that would be exacerbated by CPR or other resuscitation procedures. A paramedic, EMT or any medical personnel who comes across an individual/patient with a valid DNR order must refrain from attempting any resuscitative procedures, and will not be held liable for the death of the individual. The patient’s physician must approve of a DNR, confirming the patient’s condition by signing the DNR form. Aside from the patient’s and physician’s signatures, two (2) witnesses are required to make a DNR order valid.

Laws§ 16-36-5

Required to Sign – Patient, physician and two (2) witnesses.

How to Write

Step 1 – Download the DNR form in Adobe PDF.

Step 2 – Enter the date in the first available fields near the top of the form.

Step 3 – The declarant, i.e., the patient or their legal representative, must sign their name, print their name, and enter their city and state of residence.

Step 4 – Two (2) witnesses (for specifications see § 16-36-5-2; “Competent Witness”) must sign, print their names and provide the date on which the form was signed.

Step 5 – The last section of the form must be completed by the patient’s physician. They must enter their full name, their patient’s name, their signature, their medical license number and the date.


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