Illinois Do Not Resuscitate Order (DNR)
This Do Not Resuscitate Order (DNR) is created in accordance with the Illinois Compiled Statutes, Chapter 755 ILCS 35, the Illinois DNR law. It communicates your wishes regarding emergency medical treatment.
Patient Information:
- Name: _______________________________
- Date of Birth: ________________________
- Address: _____________________________
- Emergency Contact Name: _______________
- Emergency Contact Phone Number: _________
Physician Information:
- Physician's Name: ______________________
- Physician's Phone Number: ______________
- Medical License Number: _______________
Patient’s Wishes:
I, the undersigned, do not wish to receive cardiopulmonary resuscitation (CPR) or any other life-sustaining treatment in the event of a cardiac or respiratory arrest. This DNR order applies to the following:
- Cardiac arrest
- Respiratory failure
Patient's Signature:
_____________________________ Date: _______________
Witness Signature:
_____________________________ Date: _______________
Healthcare Provider's Signature:
_____________________________ Date: _______________
This document should be kept in a location easily accessible to medical personnel. A copy of this DNR order should also be provided to your physicians and emergency contacts.
