Florida Do Not Resuscitate Order
This form is a legal document that communicates your wishes regarding resuscitation efforts if you experience a medical emergency. It complies with Florida state law, specifically Chapter 401.45 of the Florida Statutes.
Please complete the following information:
- Patient's Name: _______________________
- Patient's Date of Birth: _______________________
- Patient's Address: _______________________
- City: _______________________
- State: FL
- ZIP Code: _______________________
- Patient's Social Security Number: _______________________
- Designated Health Care Surrogate (if applicable): _______________________
- Contact Number: _______________________
I, the undersigned, appoint the following statement as my Do Not Resuscitate Order:
Order: If I should suffer a cardiac arrest or respiratory failure, do not attempt resuscitation. This includes but is not limited to CPR, intubation, and advanced cardiac life support.
This decision has been made after discussions with my healthcare providers, my surrogate, and my loved ones.
Please sign and date below:
- Patient's Signature: _______________________
- Date: _______________________
If applicable, signatures from witnesses or a notary public are encouraged but not required. This may strengthen the validity of the document.
Witness Signature (if applicable): _______________________
Date: _______________________
Witness Signature (if applicable): _______________________
Date: _______________________
Ensure that copies of this order are provided to your healthcare providers and kept in your medical records.
