Can a DNR be signed electronically?

Yes in most jurisdictions if the electronic process meets ESIGN (15 U.S.C. §7001) and the state’s UETA or ESRA standards; confirm local witness/notary requirements before relying solely on an electronic signature.

Who may sign when a patient lacks capacity?

A legally authorized surrogate or healthcare agent may sign consistent with state advance directive statutes and any documented hierarchy; record the surrogate’s authority on the form and in the chart.

Are witnesses or notarization always required?

Requirements vary by state and facility policy; some states accept witness signatures while others require notarization. Check applicable state rules or institutional procedures before finalizing the form.

How can the form be revoked or changed?

Patients may revoke or replace directives by signing a new form or clearly documenting revocation; clinicians should attach superseding forms to the record and notify care teams immediately.

What are HIPAA considerations for sharing the form?

Treat the form as protected health information. Disclose only on a need‑to‑know basis and ensure a BAA is in place with any vendor processing PHI electronically.

How should signed copies be stored long term?

Store the signed form in the EHR and a secure document archive with tamper evidence and audit trails. Maintain retention in line with HIPAA (45 CFR §164.530(j)) and any state requirements.

Electronic Signature
Templates
Healthcare
Healthcare Patient Consent and DNR Form

Healthcare Patient Consent and DNR Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

HEALTHCARE PATIENT CONSENT AND DNR FORM

Patient Information

Patient Full Legal Name

Date of Birth

Gender

Address

Primary Phone

Email Address

Emergency Contact

Contact Name

Relationship

Contact Phone

Insurance Information

Insurance Provider

Policy Number

Group Number

Subscriber Name

Medical History

Current Medications Known Allergies

No known drug or material allergies

Prior Surgeries / Hospitalizations Chronic Conditions / Diagnoses

Consent for Treatment

I, the undersigned, hereby authorize and consent to medical and surgical treatment, diagnostic procedures, anesthesia, and other care as may be recommended by my treating clinicians. I understand that medicine and surgery involve risks, which may include but are not limited to infection, bleeding, allergic reaction, organ injury, need for additional procedures, persistent pain, disability, or death. No guarantee has been made to me as to the results of any treatment or procedure.

Planned Procedure or Intervention Indication / Reason for Procedure

I certify that the proposed treatment, its risks, benefits, expected outcomes, and reasonable alternatives (including the option of no treatment) have been explained to me in terms I understand. I have had the opportunity to ask questions and these have been answered to my satisfaction.

I acknowledge that I have had the opportunity to ask questions about the procedure, risks, benefits, and alternatives.

Do Not Resuscitate (DNR) Directive

The following selections indicate my preferences regarding resuscitation and life-sustaining treatment in the event of cardiac or respiratory arrest. I understand that this directive applies to cardiopulmonary resuscitation (CPR) and advanced cardiac life support measures unless otherwise specified below.

Do Not Resuscitate (DNR): Withhold chest compressions, defibrillation, and advanced airway management in the event of cardiac or respiratory arrest.

Do Not Intubate (DNI): Withhold endotracheal intubation and mechanical ventilation; other resuscitative measures may be given as appropriate.

Comfort Measures Only: Provide only measures directed toward comfort and symptom control; do not initiate life-prolonging treatments.

Full Code: Attempt all appropriate resuscitative measures, including CPR and advanced life support.

Additional directives or clarifications regarding DNR/DNI Directive Effective Until

I understand that this DNR directive may be subject to institutional policies and applicable law. If I am transferring between care settings, I consent to communication of this directive to receiving providers as necessary for continuity of care.

Privacy and Authorization

I acknowledge receipt of the facility's notice of privacy practices and understand that my health information may be used and disclosed for treatment, payment, and healthcare operations in accordance with applicable law. I authorize the release of medical information as necessary for care coordination and insurance purposes.

I acknowledge receipt of the privacy notice and authorize disclosure of my health information as described above.

Revocation and Certification

I understand that I may revoke this consent or DNR directive at any time by providing written notice to my treating provider or facility, except to the extent that action has already been taken in reliance on this consent. Revocation is not effective retroactively to invalidate actions taken prior to receipt of written revocation.

By signing below I certify that I am the patient or the legally authorized representative of the patient, that I understand the nature and consequences of the decisions set forth in this form, and that the decisions are made voluntarily.

I certify that I have read (or had read to me) this form, understand its contents, and have had the opportunity to ask questions.

Patient Name:

By:

Date:

Relationship to Patient (if signing as representative):

If representative, authority to sign:

What the Healthcare Patient Consent and DNR Form Is

The Healthcare Patient Consent and DNR Form documents a patient’s informed permission for medical treatment together with a Do-Not-Resuscitate (DNR) directive specifying limitations on cardiopulmonary resuscitation and related life‑sustaining measures. It records patient identity, decision‑making capacity, any surrogate or proxy designation, and the exact scope of consent or refusal. Clinicians, hospitals, and emergency responders rely on the form to guide care consistent with patient wishes. Electronic execution is often acceptable under ESIGN (15 U.S.C. §7001) and state UETA/ESRA rules, though witness or notarization requirements vary by jurisdiction.

Why a Combined Consent and DNR Form Matters

A consolidated form reduces confusion during emergencies, creates a clear legal record of patient preferences, and supports continuity of care. Proper completion lowers clinical and liability risk, facilitates rapid access to directives, and—when compliant with HIPAA and ESIGN/UETA—can be executed electronically for secure, auditable storage.

Who Completes and Signs This Form

Typical participants involved in completing and relying on the form include clinical staff, patients, and legally authorized representatives.

Patients making explicit treatment preferences and DNR decisions to record their wishes clearly.
Physicians, nurse practitioners, and attending clinicians who confirm capacity and explain medical consequences.
Designated surrogates, healthcare proxies, or legal representatives signing when a patient lacks decision‑making capacity.

Clear role assignment and consistent recordkeeping reduce disputes and delays when urgent treatment decisions arise.

Core Elements Included in a Professional Form

A complete form contains identity, capacity assessment, explicit DNR instructions, surrogate designation, witness/notary fields, and signature metadata for legal clarity and clinical use.

Patient ID

Full legal name, date of birth, and medical record number to unequivocally link the directive to the correct patient and chart.

Capacity

Clinician statement confirming the patient’s decision‑making capacity or, if lacking, documentation of the legal authority for a surrogate to act.

DNR Directive

Clear yes/no selections and checkboxes describing specific interventions to withhold, such as CPR, intubation, or defibrillation.

Surrogate

Name, contact information, and legal authority of a proxy or healthcare agent authorized to make decisions if the patient is incapacitated.

Witness/Notary

Designated witness signature lines and notarization block if the state or facility requires authentication to validate the directive.

Signatures

Patient and clinician signature fields with printed names, relationship, and dates; include space for initials on each page when used.

Security and Compliance Checklist

Encryption: TLS 1.2/1.3; AES‑256 at rest

HIPAA: BAA required for PHI exchange

Audit Trail: Timestamped events and IP log

Access Controls: Role‑based permissions

Authentication: Email, SMS, or stronger

Retention: Immutable copies with versioning

Step-by-Step: Completing the Form

Follow these steps to ensure the form is complete, enforceable, and accessible to care teams when needed.

01

Identify: Enter full legal name, DOB, and MRN exactly.
02

Explain: Clinician documents informed‑consent discussion and alternatives.
03

Select: Mark DNR options and any limited treatments precisely.
04

Authenticate: Obtain required signatures, witnesses, or notarization per state rules.

How to Configure an Online Workflow for This Form

Set up digital fields, authentication, and routing so signed forms reach care teams and records systems automatically.

Field	Configuration
Signature Fields	Place patient, clinician, and witness signature tags with date stamps
Authentication	Use email+SMS code or stronger ID proofing for high‑risk cases
Conditional Logic	Show surrogate fields only if patient lacks capacity
Notifications	Auto‑send copies to EHR inbox and designated proxies

Typical Digital Submission Flow

A concise sequence from creation to archival ensures form availability in clinical workflows.

Upload: Sender uploads template and customizes fields.
Assign: Assign patient, clinician, and witness roles.
Authenticate: Signers verify identity and sign.
Store: Signed copy stored with audit trail.

Technical Requirements for Electronic Handling

Ensure the signing platform supports secure PDF/DOCX handling, audit trails, and appropriate signer authentication.

File Formats: PDF and DOCX supported
Integrations: EHR, Google Workspace, Box
Authentication: Email, SMS, or KBA

Timing and Review Expectations

Complete and document the form at the earliest appropriate point, and review after key clinical changes.

Initial Completion:

At admission or before a procedure when treatment choices change.

Periodic Review:

Revisit directives after major diagnosis or capacity changes.

Effective Date:

Use MM/DD/YYYY to establish when the directive takes effect.

Updates:

Record revisions and replacement dates when a new form supersedes prior versions.

Emergency Use:

Make signed copy available to EMS and on‑call teams immediately.

Common Mistakes to Avoid

Using initials instead of full signatures on the final page, which can create enforceability questions in clinical settings.
Failing to include exact dates or using ambiguous date formats that impede electronic record matching and retrieval.
Omitting witness or notary details when state law or institutional policy requires them, risking invalidation of the directive.
Storing signed copies only in email threads rather than secure EHR or document management systems, increasing HIPAA and continuity risks.

Legal and Clinical Risks of an Incorrect Form

Invalid Directive: May be unenforceable

HIPAA Breach: Unauthorized disclosure risk

Clinical Delay: Care decisions may be postponed

Malpractice Exposure: Increased liability risk

Insurance Denial: Coverage disputes possible

Probate Dispute: Estate challenges may follow

eSignature Vendor Comparison for Healthcare Consent and DNR Workflows

Compare common capability and pricing dimensions for eSignature vendors when selecting a platform for secure patient directives and consent forms.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7‑day free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes (Business Premium)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA)	Yes	Yes	No	No

Frequently Asked Questions

Answers to common legal, technical, and procedural questions about completing and relying on the Healthcare Patient Consent and DNR Form.

Need help? Contact support

Can a DNR be signed electronically?
Yes in most jurisdictions if the electronic process meets ESIGN (15 U.S.C. §7001) and the state’s UETA or ESRA standards; confirm local witness/notary requirements before relying solely on an electronic signature.
Who may sign when a patient lacks capacity?
A legally authorized surrogate or healthcare agent may sign consistent with state advance directive statutes and any documented hierarchy; record the surrogate’s authority on the form and in the chart.
Are witnesses or notarization always required?
Requirements vary by state and facility policy; some states accept witness signatures while others require notarization. Check applicable state rules or institutional procedures before finalizing the form.
How can the form be revoked or changed?
Patients may revoke or replace directives by signing a new form or clearly documenting revocation; clinicians should attach superseding forms to the record and notify care teams immediately.
What are HIPAA considerations for sharing the form?
Treat the form as protected health information. Disclose only on a need‑to‑know basis and ensure a BAA is in place with any vendor processing PHI electronically.
How should signed copies be stored long term?
Store the signed form in the EHR and a secure document archive with tamper evidence and audit trails. Maintain retention in line with HIPAA (45 CFR §164.530(j)) and any state requirements.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now