DNR ORDER FORM
A printed copy of this order form or other authorized
DNR identification must accompany the patient during
transports and transfers between facilities.
Patient Birth Date:
Optional Patient or Authorized Representatives Signature
Printed name of Physician, APRN or PA*
REQUIRED Signature of Physician, APRN or PA
REQUIRED for APRN or PA: Name of the supervising physician (PA) or collaborating physician (APRN) for this patient and the physician’s NPI, DEA or Ohio medical
CHECK ONLY ONE BOX BELOW
DNR Comfort Care — Arrest: Providers will treat patient as any other without a DNR order until the point of cardiac
or respiratory arrest at which point all interventions will cease and the DNR Comfort Care protocol will be implemented.
DNR Comfort Care: The following DNR protocol is effective immediately.
Providers Will Not:
Conduct an initial assessment
Perform Basic Medical Care