Fill and Sign the Colorado Dnr Form

Patient’s or Authorized Agent’s Directive to Withhold Cardiopulmonary Resuscitation (CPR) This template is consistent with rules adopted by the Colorado State Board of Health at 6 CCR 1015-2 Patient’s Information Patient’s Name _______________________________ (Printed Name) If Applicable - Name of Agent/Legally Authorized Guardian/Parent of Minor Child _______________________________ (Printed Name) Date of Birth: _____/____/_____ Gender: Male Female Eye Color: ________________________ Hair Color: ________________________ Race Ethnicity : Asian or Pacific Islander Black, non-Hispanic White, non-Hispanic American Indian or � Alaska Native Hispanic Other If Applicable - Name of hospice program/provider: ________________________ Physician’s Information Physician’s Name: ________________________ (Printed Name) Physician’s Address: ________________________ Physician’s telephone: ________________________ Physician’s Colorado License #: ________________________ Directive Attestation Check ONLY the information that applies: 1 Patient : I am over the age of 18 years, of sound mind and acting voluntarily. It is my desire to initiate this directive on my behalf. I have been advised that as a result of this directive, if my heart or breathing stops or malfunctions, I will not receive CPR and I may die. 2 Authorized Agent/Legally Authorized Guardian/Parent of Minor Child : I am over the age of 18 years, of sound mind, and I am legally authorized to act on behalf of the patient named above in the issuance of this directive. I have been advised that as a result of this directive, if the patient’s heart or breathing stops or malfunctions, the patient will not receive CPR and may die. 3 Tissue Donation : I hereby make an anatomical gift, to be effective upon my death of: Any needed tissues The following tissues: Skin Cornea Bone, related tissues and tendons I hereby direct emergency medical services personnel, health care providers, and any other person to withhold cardiopulmonary resuscitation in the event that my/the patient’s heart or breathing stops or malfunctions. I understand that this directive does not constitute refusal of other medical interventions for my/the patient’s care and comfort. If I/the patient am/is admitted to a health care facility, this directive shall be implemented as a physician’s order, pending further physician’s orders. 1 _____________________________________ ________________________________ 2 3 Signature of Patient Physician Signature 4 Authorized Agent/Legally Authorized Guardian/Parent of Minor Child 5 _____________________________________ ________________________________ Date Date