Tennessee Do Not Resuscitate FormTennessee Do Not Resuscitate Form
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CPR

STATE OF TENNESSEE

EMERGENCY MEDICAL SERVICES
DO NOT RESUSCITATE (DNR)
ORDER
Patient’s Full Name
ATTENDING PHYSICIAN’S STATEMENT
I am the attending physician of the patient named above and direct medical personnel not initiate cardiopulmonary
resuscitation on this patient. I understand that I may revoke these directions at any time.

Date

signature of Attending Physician
PRINTED NAME OF ATTENDING PHYSICIAN

THIS ORDER REMAINS IN EFFECT UNTIL THE DEATH OF THE
PATIENT OR THE DOCUMENT IS DESTROYED
PATIENT’S STATEMENT
I, the undersigned patient, or agent with a durable power of attorney for health care, direct that cardiopulmonary
resuscitation should not be initiated. I understand that I may revoke these directions at any time.

Signature of Witness

Signature of Patient

Printed Name of Witness

Printed Full Name of Patient

Date

Signature of DPAH/C

Printed Full Name of Person Acting with durable
power of attorney for health care
THIS FORM WILL ACCOMPANY THE PATIENT DURING AMBUL