Georgia Do Not Resuscitate Order (DNR)
This Do Not Resuscitate Order (DNR) form is designed to comply with the laws of the state of Georgia. It allows individuals to express their wishes concerning resuscitation efforts in case of a medical emergency. Please fill out the information below to ensure your preferences are clearly articulated.
Patient Information:
- Full Name: _______________________________
- Date of Birth: ___________________________
- Address: _________________________________
- City: _______________ State: _______________ Zip Code: ___________
Authorized Representative:
- Full Name: _______________________________
- Relationship to Patient: ___________________
- Phone Number: ___________________________
Medical Information:
- Primary Physician’s Name: ________________
- Primary Physician’s Phone Number: _________
Order Statement:
I, the undersigned, hereby declare that I do not wish to receive cardiopulmonary resuscitation (CPR) or advanced life support in case of cardiac or respiratory arrest.
Patient Signature: _________________________ Date: _______________
Authorized Representative Signature: _________________________ Date: _______________
This DNR order should be honored by all medical personnel and facilities. It is advisable to keep a copy at home, provide a copy to your physician, and bring a copy to any hospital visit.
By signing this document, you affirm that these choices reflect your wishes regarding emergency medical care. If any revisions occur, a new DNR order must be completed.
Important Notes:
- Review this DNR order regularly to ensure it remains current.
- Provide copies of this order to family members and healthcare providers.
For more information on DNR orders in Georgia, consult with a healthcare professional or legal advisor.
