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Wisconsin Do Not Resuscitate (DNR) Order Form

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Wisconsin Do Not Resuscitate (DNR) Order Form

Updated July 19, 2023

The Wisconsin do not resuscitate (DNR) order form is used to notify emergency medical personnel that an individual should not receive life-saving treatments to restore their circulation or breathing. A patient who qualifies for a DNR order must have a terminal medical condition that would not benefit from resuscitation as determined by a licensed physician. If the patient is approved for a DNR order, the physician must complete the document below and request an identifying DNR bracelet; emergency personnel will not honor the DNR order unless a DNR bracelet accompanies the patient.

Laws § 154.17 through § 154.29

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

How to Write

Step 1 – Download the Wisconsin DNR order form in PDF.

Step 2 – Begin filling out the form by choosing one (1) of the boxes on the left to specify the patient’s gender. Next, enter the patient’s name and date of birth.

Step 3 – In the following set of entry fields, provide the patient’s street number, street name, city, state, and zip code.

Step 4 – The patient (or authorized representative) must provide their signature above the first signature field before entering the date on the right.

Step 5 – In the next two (2) spaces, the attending physician must print their name and enter their telephone number.

Step 6 – Complete the form by having the attending physician provide their signature followed by the date.