Georgia Do Not Resuscitate Order
This is a Do Not Resuscitate (DNR) order in accordance with the laws of the State of Georgia. This document states that in the event of a medical emergency where the heart stops or breathing ceases, resuscitation efforts should not be initiated.
Patient Information:
- Name: _________________________________
- Date of Birth: _________________________
- Address: _______________________________
- City, State, Zip: _______________________
Patient’s Health Care Agent (if applicable):
- Name: _________________________________
- Relationship: __________________________
- Phone Number: _________________________
Attending Physician Information:
- Name: _________________________________
- Contact Number: ______________________
Patient’s Wishes:
The patient has expressed their wish not to receive CPR or other life-sustaining treatments in the event of cardiac or respiratory arrest.
Signatures:
- Patient or Legal Representative Signature: ________________________ Date: ____________
- Attending Physician Signature: _____________________________ Date: ____________
It is recommended that copies of this DNR order be shared with family members and placed in a location readily accessible to emergency medical personnel. Please keep this document in a safe place.
This document is valid only if signed by the patient or a legal representative and a licensed physician.