Georgia Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is established in accordance with the laws of the State of Georgia. It is essential to have clarity regarding your wishes in medical emergencies.
Patient Information:
- Name: _______________________________
- Date of Birth: ______________________
- Address: ____________________________
Statement of Wishes:
I, the undersigned, hereby declare that I do not wish to receive cardiopulmonary resuscitation (CPR) or any other lifesaving measures in the event of my cardiac arrest or respiratory failure. I request that health care providers respect my wishes as outlined in this document.
Healthcare Proxy Information:
- Name: _______________________________
- Phone Number: _______________________
- Relationship: ________________________
Signature:
By signing below, I confirm that I understand the implications of this Do Not Resuscitate Order and that it reflects my wishes regarding medical treatment.
Signature of Patient or Authorized Representative: _________________________
Date: _______________________________
Witness Signature: _________________________
Date: _______________________________
This order should be kept in an accessible place and shared with all healthcare providers involved in the patient’s care.