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DNR Form City of Williston - Emergency Medical Services Pre-Hospital Do Not Resuscitate (DNR) Form An Advance Request to Limit the Scope of Emergency Medical Care I, _______________________________________, of____________________________________________________, (Print Patient’s name (required)) (Street, City, State, ZIP) request limited emergency care as herein described. My telephone number is (_ _ _) _ _ _-_ _ _ _ My Social Security Number is_ _ _/_ _/_ _ _ _ and my date of birth is ___________________(required). Sex (please circle one):
Male
Female
I understand DNR means that if my heart stops beating or if I stop breathing, no medical procedure to restart breathing or heart functioning will be instituted. I understand this decision will not prevent me from obtaining other emergency medical care by pre-hospital emergency medical care personnel and/or medical care directed by a physician prior to my death. I understand I may revoke this directive at any time by destroying this form, notifying Williston Ambulance Service in writing, and removing my “DNR” medallions. I give my permission for this information to be given to the pre-hospital emergency care personnel, doctors, nurses, or other health personnel as necessary to implement this directive. I hereby agree to the “Do Not Resuscitate” (DNR) order. I also understand that the Ambulance may have been called and there are situations in which conflicting directives may be given by family and others resulting in attempts being made to resuscitate me. In consideration of utilizing this DNR request I, on behalf of myself and my heirs release any claim for damages resulting from such attempted resuscitation I may have against any emergency response personnel, the Williston Ambulance Service, the City of Williston, and the 911 system. _______________________________________________ Patient/Surrogate Signature
_______________ Date
_____________________________________________________________________ Surrogate’s Relationship to Patient Please attach original or certified copy of medical power of attorney or court order appointing surrogate (required if surrogate signs) STATE OF NORTH DAKOTA ) :ss COUNTY OF WILLIAMS) Subscribed and sworn before me this __________ day of ___________, 20_______ (SEAL)
______________________________ Notary Public My Commission Expires:
I affirm that this patient/surrogate is making an informed decision that this directive is the expressed wish of the patient/ surrogate. A copy of this form is in the patient’s permanent medical record. In the event of cardiac or respiratory arrest, no chest compressions, assisted ventilations, intubations, defibrillation, or cardiotonic medications are to be initiated. _________________________________________ Physician Signature
______________________ Date
Physician’s Address (required): ______________________________________________ (City, State, Zip)
****The Patient MUST send or deliver this original form to the**** Williston Ambulance Service, P.O. Box 2169, 317-11th St West, Williston, ND 58802-2169 This Form will not be accepted if it has been amended or altered in any way. WILLISTON AMBULANCE SERVICE APPROVAL This form is APPROVED / NOT APPROVED. If not approved, return form to patient with note as to why it has not been approved and retained a copy of such DNR and note saying why it is not approved. If approved, forward the form to 911 Service. This form has been reviewed and ACCEPTED / NOT ACCEPTED by _______________________________ on ________________ (Williston Ambulance Employee)
(Date)
911 RECORDING INFORMATION
I, ______________________________(Please Print Name), received this form on this ________ day of __________________, 20_____. I, ____________________________(Printed Name), have put the above DNR information in the file for the above person and Social Security number listed in the DNR on this ___________ day of ____________________, 20_______, and sent the copies by regular mail to the following: Pre-Hospital DNR Request Form One copy: One copy:
To patient ___________ (Initial) To doctor ____________(Initial)
