Fill and Sign the Patients Statement Form

State of Florida DO NOT RESUSCITATE ORDER (please use ink) Patient’s Full Legal Name: Date: (Print or Type Name) PATIENT’S STATEMENT Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn. (If not signed by patient, check applicable box): □ Surrogate □ Proxy (both as defined in Chapter 765, F.S.) □ Court appointed guardian □ Durable power of attorney (pursuant to Chapter 709, F.S.) (Applicable Signature) (Print or Type Name)
Patient's date of birth: □ date: (print or type date) □ d : (print or type name) patient's date of death: □ decedent's date of death: □ designated decedent's date of death: □ designated surviving next of kin's date of death: □ designated surviving spouse's date of death: □ designated surviving minor's date of death: □ designated surviving parent's date of death: □ designated surrogate's date of death: □ designated guardian (under chapter 76) or designated court appointed guardian (under chapter 709) □ designated court appointed proxy (under chapters 709 and 762) patient's date of naturalization: □ dat (print or type date) □ date: (print or type name) patient's date of death (if applicable): □ decedent's date of death (if applicable): □ designated decedent's date of death (if applicable): □ designated surviving next (if applicable): □ designated surviving spouse's date of death (if applicable): □ designated surviving minor's date of death (if applicable): □ designated surviving parent's date of death (if applicable): □ designated surrogate's date of death (if applicable): patient's medical marijuana card number (or other government issued, verified identification): □ valid date: □ (print or type name) patient identification card (form mmc-4): □ date: □ (print or type name) patient information for medical marijuana program compliance (form mmc-5): □ date: □ (print or type name) patient information for medical marijuana program compliance for children (form mc-4): □ date: □ (print or type name) patient registration card (form mc-13): □ date: □ (print or type name) patient information for medical marijuana program compliance for adults (form mc-4): □ date: □ (print or type name) patient information for medical marijuana program compliance for persons with a disability (form mc-4): □ date: □ (print or type name) patient information for medical marijuana program compliance for persons who are blind or visually impaired (form mc-4): □ date: □ (print or type name) patient information