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Fill and Sign the Revocation of Oklahoma Form

Fill and Sign the Revocation of Oklahoma Form

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REVOCATION OF OKLAHOMA DO-NOT-RESUSCITATE (DNR) CONSENT FORM (Oklahoma Statutes, Title 63, Chapter 61A) I, , Declarant, executed a Do-Not-Resuscitate Consent Form on the day of , 20 , stating that if my heart were to stop beating or if I were to stop breathing, that no medical procedure to restore breathing or heart function should be instituted by any health care provider including, but not limited to, emergency medical services (EMS) personnel. Oklahoma Statutes 63-3131.7 provides that I may revoke this Do-Not-Resuscitate Consent Form as follows:(A)At any time, a person under the care of a health care agency may revoke such person's do-not-resuscitate consent by making an oral, written, or other act of communication to a physician or other health care provider of a health care agency.(B)At any time, a person not under the care of a health care agency may revoke such person's do-not-resuscitate consent by destroying the form and removing all do-not- resuscitate identification from the person. The person is responsible for notifying such person's attending physician of the revocation.(C) At any time, the parent or guardian of a minor child, or the minor child, if capable of doing so and possessing sufficient understanding and appreciation of the nature and consequences of the treatment decision despite the minor child's chronological age, may revoke the do-not-resuscitate consent for the minor child by making an oral, written, or other act of communication to a physician or other health care provider. The parent or guardian of the minor child is responsible for notifying the minor child's attending physician of the revocation.(D)At any time, a representative may revoke the do-not-resuscitate consent for an incapacitated person under the care of a health care agency by notifying a physician or other health care provider of the health care agency of the revocation of consent in writing or by orally notifying the attending physician.(E)At any time, a representative may revoke the do-not-resuscitate consent for an incapacitated person not under the care of a health care agency by destroying the form and removing all do-not-resuscitate identification from the person. The representative is responsible for notifying the person's attending physician of the revocation. This is my written revocation of my Do-Not-Resuscitate Consent Form and is provided to all persons to whom I have provided a copy of my Do-Not-Resuscitate Consent Form, including my physician.DATED this the day of , 20 . Signature of Declarant: __________________________________________________________Printed Name of Declarant: Address of Declarant:

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