New Hampshire Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is in accordance with New Hampshire state laws regarding end-of-life care. It allows individuals to express their wishes regarding resuscitation efforts in the event of a medical emergency.
Patient Information:
- Name: ____________________________
- Date of Birth: _____________________
- Address: __________________________
- Phone Number: _____________________
Physician Information:
- Physician Name: _____________________
- Medical License Number: _____________
- Phone Number: ______________________
Patient's Wishes:
The patient, named above, wishes to refuse resuscitation efforts in the event of cardiac arrest or respiratory failure. This decision is made voluntarily and is based on the patient's values and beliefs.
Signatures:
By signing below, the patient and physician acknowledge and agree to the terms of this Do Not Resuscitate Order.
- Patient Signature: ______________________ Date: ___________
- Physician Signature: ____________________ Date: ___________
This DNR Order is effective immediately upon signing and remains in effect until revoked by the patient or a legally authorized representative.