Fill and Sign the Dnr 481377522 Form

FRONT PAGE OKLAHOMA DO-NOT-RESUSCITATE (DNR) CONSENT FORM I, ____________________________, request limited health care as described in this document. If my heart stops beating or if I stop breathing, no medical procedure to restore breathing or heart function will be instituted by any health care provider including, but not limited to, emergency medical services (EMS) personnel. I understand that this decision will not prevent me from receiving other health care suc h as the Heimlich maneuver or oxygen and other comfort care measures. I understand that I may revoke this consent at any time in one of the following ways: 1. If I am under the care of a health care agency, by making an oral, written, or other act of communication to a physician or other health care provider of a health care agency; 2. If I am not under the care of a health care agency, by destroying my do-not-resuscitate form , removing all do-not-resuscitate identification from my person, and notifying my attending physician of the revocation; 3. If I am incapacitated and under the care of a health care agency, my representa tive may revoke the do-not-resuscitate consent by written notification to a physician or other healt h care provider of the health care agency or by oral notification to my attending physician; or 4. If I am incapacitated and not under the care of a health care agency, my repre sentative may revoke the do-not-resuscitate consent by destroying the do-not-resuscitate form, removing all do- not-resuscitate identification from my person, and notifying my attending physician of the revocation. I give permission for this information to be given to EMS personnel, doctors, nurses, and other health care providers. I hereby state that I am making an informed decision and agree to a do- not-resuscitate order. __________________ OR _______________________________________. Signature of Person Signature of Representative (Limited to an attorney-in-fact for health care decisions acting under the Dura ble Power of Attorney Act, a health care proxy acting under the Oklahoma Advance Directive Act or a guardian of the person appointed under the Oklahoma Guardianship and Conservatorship Act.) This DNR consent form was signed in my presence. ___________________ _____________________ _______________________ Date Signature of Witness Address ___________________ _____________________ _______________________ Date Signature of Witness Address BACK OF PAGE CERTIFICATION OF PHYSICIAN (This form is to be used by an attending physician only to certify that an incapacit ated person without a representative would not have consented to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. An attending physician of an incapacitated person without a representative must know by clear and convincing evidence that the incapacitated person, when competent, decided on the basis of information sufficient to constitute informed consent that such person would not have consented to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. Clear and convincing evidence for this purpose shall include oral, written, or other acts of communication between the patient, when competent, and family members, health care providers, or others dose to the patient with knowledge of the patient's desires.) I hereby certify, based on clear and convincing evidence presented to me, that I beli eve that ____________________________ Name of Incapacitated Person would not have consented to the administration of cardiopulmonary resuscitation in the e vent of cardiac or respiratory arrest. Therefore, in the event of cardiac or respiratory arrest, no c hest compressions, artificial ventilation, intubations, defibrillation, or emergency cardiac m edications are to be initiated. ____________________________ Physician's Signature/Date ____________________________ Physician's Name (PRINT) ____________________________ Physician's Address/Phone