Colorado Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is made in accordance with Colorado state laws. This document expresses the wishes of the individual regarding resuscitation efforts in the event of a medical emergency.
Patient Information:
- Name: __________________________
- Date of Birth: ___________________
- Address: _________________________
- Phone Number: ____________________
Healthcare Proxy Information:
- Name: __________________________
- Relationship: _____________________
- Phone Number: ____________________
Statement of Wishes:
I, the undersigned, do not wish to receive cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS) in the event of cardiac arrest or respiratory failure.
This order is effective immediately and remains in effect until revoked by me or my authorized representative.
Signature: ____________________________
Date: _______________________________
Witness Information:
- Name: __________________________
- Signature: ______________________
- Date: __________________________
This document should be kept in a location where it can be easily accessed by healthcare providers. It is advisable to provide copies to your healthcare proxy, family members, and primary care physician.