Who is this Do Not Resuscitate Order for? Patient's date of birth: Where does this person live? SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming Parties to this agreement vary by state. If you don't select a state, the default signatories are the patient and the physician. Is this person competent? Is this person competent? YesNo Does the named party have the mental and physical capacity to make decisions about their care? Is this person competent? Is this person competent? YesNo Does the named party have the mental and physical capacity to make decisions about their care? Is this person competent? Is this person competent? YesNo Does the named party have the mental and physical capacity to make decisions about their care? Is this person competent? Is this person competent? YesNo Does the named party have the mental and physical capacity to make decisions about their care? Is this person competent? Is this person competent? YesNo Does the named party have the mental and physical capacity to make decisions about their care? Is the patient a minor? Is the patient a minor? YesNo Is this person competent? Is this person competent? YesNo Does the named party have the mental and physical capacity to make decisions about their care? Who's signing? Who's signing? Attorney-in-Fact (named in Medical Power of Attorney)GuardianAuthorized Representative (named in Advance Directive/Living Will)Healthcare Surrogate (named in Health Care Surrogate Designation) Who's signing? Who's signing? Attorney-in-Fact (named in Medical Power of Attorney)GuardianAuthorized Representative (named in Advance Directive/Living Will)Healthcare Surrogate (named in Health Care Surrogate Designation) Who's signing? Who's signing? Attorney-in-Fact (named in Medical Power of Attorney)GuardianAuthorized Representative (named in Advance Directive/Living Will)Healthcare Surrogate (named in Health Care Surrogate Designation) Who's signing? Who's signing? Attorney-in-Fact (named in Medical Power of Attorney)GuardianAuthorized Representative (named in Advance Directive/Living Will)Healthcare Surrogate (named in Health Care Surrogate Designation) Who's signing? Who's signing? Attorney-in-Fact (named in Medical Power of Attorney)GuardianAuthorized Representative (named in Advance Directive/Living Will)Healthcare Surrogate (named in Health Care Surrogate Designation) Who's signing? Who's signing? Attorney-in-Fact (named in Medical Power of Attorney)GuardianAuthorized Representative (named in Advance Directive/Living Will)Healthcare Surrogate (named in Health Care Surrogate Designation) Name of attorney-in-fact: A copy of the medical power of attorney must be attached to this order. Name of guardian: Name of authorized representative: A copy of the advance directive/living will must be attached to this order. Name of healthcare surrogate: A copy of the Health Care Surrogate Designation must be attached to this order. Will two witnesses OR a second physician sign? Will two witnesses OR a second physician sign? Two WitnessesSecond Physician Next Save Save and finish later
