Florida Do Not Resuscitate Order
This document is a legally recognized Do Not Resuscitate (DNR) Order in accordance with Florida State laws. By completing this form, you express your wish to not receive cardiopulmonary resuscitation (CPR) if your heart stops beating or if you stop breathing.
It is important to discuss this decision with your healthcare provider and loved ones. Ensure that this order is accessible and clear to all individuals involved in your care.
Patient Information
- Patient's Name: ________________________________________
- Date of Birth: ________________________________________
- Patient's Address: ____________________________________
- City, State, Zip: _____________________________________
Healthcare Proxy Information (if applicable)
- Name of Healthcare Proxy: ____________________________
- Relationship to Patient: _____________________________
- Proxy's Phone Number: _____________________________
Statement of Wishes
By signing below, I acknowledge and understand that this Do Not Resuscitate Order indicates my refusal of CPR in the event of cardiac arrest or respiratory failure. This order does not affect other forms of medical care that I may choose to receive.
Signatures
Patient's Signature: ______________________________________
Date: _________________________________________________
Witness Information
This Order must be signed by two witnesses. The witnesses should be adults and cannot be related to the patient or entitled to any portion of the patient’s estate.
- Witness 1 Name: ______________________________________
- Witness 1 Signature: _______________________________
- Date: _____________________________________________
- Witness 2 Name: ______________________________________
- Witness 2 Signature: _______________________________
- Date: _____________________________________________
This document should be reviewed periodically and may be revoked or modified at any time.