Indiana Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is a legally recognized document in the state of Indiana. It allows individuals to express their wishes regarding resuscitation efforts in the event of a medical emergency. This document is governed by Indiana Code Title 16, Article 36, Chapter 6.5.
Please fill in the following information:
- Patient's Full Name: ___________________________
- Date of Birth: _______________________________
- Address: ____________________________________
- City, State, Zip Code: ______________________
- Phone Number: _____________________________
- Healthcare Provider's Name: ________________
- Healthcare Provider's Phone Number: __________
By signing this document, I, the undersigned, declare that I do not wish to receive cardiopulmonary resuscitation (CPR) or other life-saving measures in the event of cardiac arrest or respiratory failure. I understand that this order will be honored by medical personnel and healthcare providers.
Signature of Patient: ___________________________
Date: ______________________________________
If the patient is unable to sign, a legal representative may sign on their behalf. Please provide the following information:
- Legal Representative's Full Name: _______________
- Relationship to Patient: _______________________
- Signature of Legal Representative: ______________
- Date: ______________________________________
This DNR Order should be kept in a place where it can be easily accessed by healthcare providers. It is advisable to share copies of this document with family members and your healthcare team.
For further information regarding the legal aspects of this order, please consult with a healthcare professional or legal advisor.