» » Virginia Do Not Resuscitate (DNR) Order Form

Virginia Do Not Resuscitate (DNR) Order Form

Create a high quality document online now!

The Virginia do not resuscitate (DNR) order form is a statement letting emergency service personnel know that a patient does not want to receive life-saving treatment during a medical emergency where they are unable to breathe or do not have a heartbeat. Life-saving treatments include cardiopulmonary resuscitation (CPR), endotracheal intubation, cardiac compression, and certain airway management procedures. The order must be issued to the patient by a licensed physician who has established a relationship with the individual. Once the form is signed by both the physician and the patient (or their authorized representative), the DNR order will be effective and the individual will be exempt from resuscitation by any medical professional.

Laws – § 54.1-2987.1

Required to Sign – Patient (or representative) and physician.

How to Write

Step 1 – Download the Virginia DNR order form in Adobe PDF.

Step 2 – Proceed to the third page of the order form. The first two (2) spaces at the top of page (3) must be filled in with the patient’s full legal name and the date.

Step 3 – Below the words “I further certify,” you will need to select one (1) of the boxes to indicate whether the patient is capable or incapable of making informed medical decisions.

Select the first option if the patient is capable of making their own informed medical decisions.

Select the second option if the patient is incapable of making their own informed medical decisions.

Step 4 – This step only applies if you selected option number two (2) in the previous step. If this is the case, you must check either option A, B, or C.

Check option A if the patient has executed a written advance directive detailing their desired life-prolonging treatments.

Choose option B if the patient has executed a written advance directive which nominates a person authorized to act on their behalf and make decisions relating to the patient’s desired life-prolonging treatments.

Choose option C if the patient has no written advance directive, living will, or durable power of attorney regarding health care.

Step 5 – Proceed to the bottom of page (3) to locate the spaces pictured below. In the empty spaces, the following information must be supplied:

  • Physician’s printed name
  • Physician’s signature
  • Physician’s emergency phone number
  • Patient’s signature (if able to sign)
  • Signature of person authorized to sign on the patient’s behalf (if applicable)

Step 6 – Pages (4) and (5) of the DNR order form must be completed in the same manner as page (3). Once completed, page (3) should be kept by the patient, page (4) should be retained in the patient’s permanent medical record, and page (5) should be used when ordering identifying DNR jewelry such as a bracelet or necklace.


ABOUT SSL CERTIFICATES