Florida Do Not Resuscitate Order Template
This Do Not Resuscitate (DNR) Order is created in accordance with Florida Statutes, Chapter 401. It is essential for individuals who wish to express their preference regarding resuscitation in the event of a medical emergency.
Please fill in the following information:
- Patient's Full Name: ____________________________
- Date of Birth: ____________________________
- Patient's Address: ____________________________
- City, State, Zip Code: ____________________________
- Patient's Phone Number: ____________________________
- Healthcare Proxy Name: ____________________________
- Healthcare Proxy Phone Number: ____________________________
The undersigned hereby states that the above-named patient has a terminal condition or is in a persistent vegetative state. The patient has expressed a desire not to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. This order shall remain in effect until revoked by the patient or the patient's legally authorized representative.
Signature of Patient or Authorized Representative: ____________________________
Date: ____________________________
Witness Signature: ____________________________
Date: ____________________________
Note: This document must be signed by the patient or an authorized representative and witnessed by two adults who are not related to the patient or entitled to any portion of the patient's estate.