Massachusetts Do Not Resuscitate (DNR) Order Form
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MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
OFFICE OF EMERGENCY MEDICAL SERVICES

CCFORM 9/2006

COMFORT CARE / DO NOT RESUSCITATE
(“DNR”) ORDER VERIFICATION

PATIENT’S LAST NAME
PATIENT’S FIRST NAME

PATIENT’S MIDDLE NAME OR INITIAL

DATE OF BIRTH (MM/DD/YYYY)

GENDER

M

F

STREET OR RESIDENTIAL ADDRESS
CITY

STATE

ZIP CODE (5 or 9 digits)

LAST NAME OF GUARDIAN OR HEALTH CARE AGENT (If applicable)
FIRST NAME OF GUARDIAN OR HEALTH CARE AGENT

MIDDLE NAME OR INITIAL

PATIENT/GUARDIAN/HHEALTH CARE AGENT STATEMENT (SIGNATURE AND DATE REQUIRED)
I
( patient
guardian
health care agent)
verify that the above named patient has a current and valid Do Not Resuscitate order (“DNR order”). I understand that by signing this
form, the DNR order, if current and valid, will be recognized in out-of-hospital settings and the COMFORT CARE / Do Not Resuscitate
Order Verification Protocol will be followed by emergency medical services personnel.

Signature of Patient/Guardian/Health Care Agent

Date

PH