Florida Do Not Resuscitate Order
This document serves as a directive regarding your consent related to resuscitation efforts in the state of Florida, in accordance with Florida Statutes Section 401.45.
Patient Information:
- Full Name: __________________________
- Date of Birth: ______________________
- Address: _____________________________
Documenting Physician:
- Physician's Name: _________________________
- Practice Name: __________________________
- Phone Number: __________________________
Patient Wishes:
As the patient, I hereby express my desire regarding resuscitation efforts:
I do not wish to receive any resuscitation measures in the event of a cardiac or respiratory arrest, indicated by my signature below.
Signature: __________________________
Date: ______________________________
If this order is being executed on behalf of the patient, please provide the following information:
- Representative Name: __________________________
- Relationship to Patient: ______________________
- Signature: _________________________________
- Date: __________________________________
Witnesses:
This document requires the signature of at least two witnesses or a notary public:
- Witness 1 Name: _________________________________
- Witness 1 Signature: ___________________________
- Date: ________________________________________
- Witness 2 Name: _________________________________
- Witness 2 Signature: ___________________________
- Date: ________________________________________
This document should be kept in a safe place, readily accessible for future healthcare providers, and can be presented at the time of medical emergencies.