Georgia Do Not Resuscitate Order Template
This Do Not Resuscitate (DNR) Order is created under the laws of the state of Georgia. It is intended to provide clear instructions regarding the wishes of the individual regarding resuscitation efforts in the event of a medical emergency.
Patient Information:
- Patient's Full Name: ________________________________
- Date of Birth: ________________________________
- Address: ________________________________
- Phone Number: ________________________________
Physician Information:
- Physician's Name: ________________________________
- Medical License Number: ________________________________
- Contact Number: ________________________________
This order applies to the following:
- Patient's wishes: I do not wish to receive cardiopulmonary resuscitation (CPR) or any other life-saving treatment.
- Duration of Order: This order is effective until revoked or modified.
Signatures:
- Signature of Patient (or legal representative): ________________________________
- Date: ________________________________
- Signature of Physician: ________________________________
- Date: ________________________________
Please ensure this document is placed on file with your healthcare provider. A copy should also be kept in an accessible location for emergency personnel.