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Wisconsin Do Not Resuscitate (DNR) Order Form

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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 Adobe 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.