CMA PUBLICATIONS 1(800) 882-1262 WWW.CMANET.ORG
EMERGENCY MEDICAL SERVICES
PREHOSPITAL DO NOT RESUSCITATE (DNR) FORM
An Advance Request to Limit the Scope of Emergency Medical Care
I, _________________________________________, request limited emergency care as herein described.
(print patient’s name)
I understand DNR means that if my heart stops beating or if I stop breathing, no medical procedure to restart
breathing or heart functioning will be instituted.
I understand this decision will not prevent me from obtaining other emergency medical care by prehospital
emergency medical care personnel and/or medical care directed by a physician prior to my death.
I understand I may revoke this directive at any time by destroying this form and removing any “DNR” medallions.
I give permission for this information to be given to the prehospital emergency care personnel, doctors, nurses or
other health personnel as necessary to implement this directive.
I hereby agree to the “Do Not Resuscitat