Legal Washington Do Not Resuscitate Order Form

Washington Do Not Resuscitate Order (DNR)

This Do Not Resuscitate (DNR) order is created in accordance with the specific laws and regulations of the State of Washington. It is a medical order indicating that a person does not want to receive cardiopulmonary resuscitation (CPR) if their heart stops beating or if they stop breathing. This document is only valid in the State of Washington and should be completed under the guidance of a healthcare provider.

Personal Information

• Full Name: ___________________________________________
• Date of Birth: ________________________________________
• Address: ______________________________________________
• City: ___________________ State: WA Zip Code: _________
• Phone Number: ________________________________________

Medical Information

I, the undersigned, am aware that this order will inform medical personnel that I do not want efforts made to restart my heart or breathing if they stop. This decision is based on personal, religious, or philosophical beliefs and/not medical reasons.

Medical Provider's Name: __________________________________

Medical Provider's License Number: _________________________

Date: ____________________________________________________

Patient's or Legal Representative's Signature

This section must be completed to indicate the informed consent of the patient or their legally authorized representative.

• Patient's Signature: ___________________________________
• Date: _________________________________________________

OR

• Legal Representative's Signature: ________________________
• Relation to Patient: ___________________________________
• Date: _________________________________________________

Physician's Certification

I, the undersigned physician, affirm that the individual or their legally authorized representative has been informed of the nature and consequences of this DNR order, and to the best of my knowledge and belief, this order reflects the individual's wishes.

• Physician's Signature: __________________________________
• License Number: ________________________________________
• Date: _________________________________________________

This document must be kept in a place where it can easily be found by emergency personnel, such as on the refrigerator, or it should be carried by the patient. Duplicate copies should be provided to the patient's physician and any healthcare facilities where the patient receives care.