Fill and Sign the This Template is Consistent with Rules Adopted by the Colorado State Board of Health at 6 Ccr 1015 2 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: 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. 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. 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. _____________________________________ ________________________________ Signature of Patient Physician Signature Authorized Agent/Legally Authorized Guardian/Parent of Minor Child _____________________________________ ________________________________ Date Date