Pre-Hospital DNR Request Form
An advanced request to Limit the Scope of Emergency Medical Care
I, _____________________________, request limited emergency care as herein described.
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 pre-hospital
care providers or medical care directed by a physician prior to my death.
I understand I may revoke this directive at any time.
I give permission for this information to be given to the pre-hospital care providers, doctors, nurses or other
health care personnel as necessary to implement this directive.
I hereby agree to the “Do Not Resuscitate” (DNR) directive.
I AFFIRM THIS DIRECTIVE IS THE EXPRESSED WISH