Florida Do Not Resuscitate Order
This Do Not Resuscitate Order (DNRO) is provided in accordance with Chapter 401.45 of the Florida Statutes. It is important that this document clearly reflects your wishes regarding resuscitation efforts in emergency medical situations.
Patient Information:
- Name: ____________________________________
- Date of Birth: ______________________________
- Address: ____________________________________
- City: ______________ State: ______ Zip Code: ________
Health Care Representative (if applicable):
- Name: ____________________________________
- Relationship: ______________________________
- Contact Number: __________________________
Statement of Intent:
I, the undersigned, declare that if my heart stops, or if I stop breathing, I do not want any attempts made to resuscitate me. This includes but is not limited to chest compressions, intubation, defibrillation, or any other interventions intended to restart my heart or breathing.
Signature of Patient: ____________________________________
Date: _______________________
Witness Information:
- Name of Witness: ________________________________
- Signature of Witness: ________________________________
- Date: _______________________
This order is valid until revoked in writing by me or my representative. Ensure that a copy of this DNRO is kept with my medical records and that my healthcare providers are aware of my wishes.