| Do Not Resuscitate (DNR) Form
| Please Use Block Letter or Affix Label SOPD / Hospital No. : ........................... Name : ............................................... I.D. No : .............. Sex : ...... Age :............ Dept : ....... Team :........ Ward/Bed :.../..... |
Section I : Personal details of the maker of this DNR
Name: ACCOUNT_FIRST_NAME ACCOUNT_LAST_NAME
Identity Document No.:
Sex: SEX
Date of Birth: DOB
Home Address: ACCOUNT_ADDRESS_SINGLE_LINE
Tel. No.: TEL
Section II : The Directive
1. I, ACCOUNT_FIRST_NAME ACCOUNT_LAST_NAME being over the age of 18 years, revoke all previous DNRs made by me relating to my medical care and treatment (if any), and make the following DNR of my own free will.
2. If my heart stops beating or my breathing ceases, my directive in relation to my medical care and treatment is as follows:
I shall not be given cardiopulmonary resuscitation (CPR).
3. I make this directive in the presence of the two witnesses named in Section III of this DNR, who are not beneficiaries under my will, or any policy of insurance held by me, or any other instrument made by me or on my behalf.
4. I understand I can revoke this DNR at any time.
______________________________________ __________________
Signature of the maker of this DNR Date
Section III : Statement of Witnesses
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