Georgia Do Not Resuscitate (DNR) Order
This document serves as a Do Not Resuscitate (DNR) Order in compliance with the policies and statutes of the State of Georgia, particularly the Georgia Do Not Resuscitate Act. It is a legally binding document that indicates the undersigned's directive to not receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest.
Please fill in the following information accurately to ensure that this DNR order reflects your wishes and is recognized by healthcare providers and emergency responders in Georgia.
Patient Information:
- Full Name: _______________________________
- Date of Birth: ____________________________
- Address: __________________________________
- City: _______________ State: GA Zip: _________
Primary Physician Information:
- Name: _______________________________
- Address: __________________________________
- City: _______________ State: GA Zip: _________
- Phone Number: _____________________________
This DNR order is made on the basis of the patient's autonomous decision and understanding of the implications of such an order. It is intended to respect the patient's wishes concerning medical treatments at the end of life.
Order:
I, __________________________(Patient's Name), hereby direct that no form of cardiopulmonary resuscitation (CPR) should be administered to me by any healthcare provider, including emergency medical services personnel, in the event of my cardiac or respiratory arrest.
This DNR Order is applicable throughout the State of Georgia and is to be followed unless revoked by me or my legally authorized representative.
Signature of Patient or Legally Authorized Representative:
- Signature: _______________________________
- Date: ____________________________________
Physician's Declaration:
I, __________________________ (Physician's Name), certify that I have discussed the implications and consequences of a Do Not Resuscitate (DNR) order with the patient or their legally authorized representative. I confirm that this order represents the patient's wishes.
Signature of Physician:
- Signature: _______________________________
- Date: ____________________________________
- Medical License Number: ____________________