Arkansas Do Not Resuscitate (DNR) Order Form
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STATE OF ARKANSAS
EMERGENCY MEDICAL SERVICES
DO NOT RESUSCITATE ORDER
Patient's Full Name: _______________________________________________________________
________________________________________________
Signature of Patient or Health Care Proxy or Legal Guardian

____________________
Date

ATTENDING PHYSICIAN'S ORDER
I, the undersigned, state that I am the physician for the patient named above.
I hereby direct any and all qualified Emergency Medical Services personnel, commencing on the effective date
noted below, to withhold cardiopulmonary resuscitation (cardiac compression, endotracheal intubation and other
advanced airway management, artificial ventilation, defibrillation, administration of cardiac resuscitation
medications, and related procedures) from the patient in the event of the patient's cardiac or respiratory arrest. I
further direct such personnel to provide to the patient other medical interventions such as intravenous fluids,
oxygen, or other therapies deemed necessary