Oregon Do Not Resuscitate (DNR) Order Form – Sample OnlyOregon Do Not Resuscitate (DNR) Order Form – Sample OnlyOregon Do Not Resuscitate (DNR) Order Form – Sample Only
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Health care providers are authorized to print Oregon POLST Forms for use with their patients. The Oregon
POLST Form remains a copyright protected document and in order to print the form certain guidelines must be
followed.

Requirements and information for printing Oregon POLST Forms
The form must not be altered in any way including the overall layout, text, or images.
Copy or print forms on 65# Cover Ultra Pink card stock*
Both side of the form must be printed back to back and not on separate pages
A POLST Form requires a signature from an MD, DO, PA, or NP to be valid and should only be filled
out and signed after an in-depth conversation between the patient and health care provider about the
patient’s goals of care
The Oregon POLST Form is updated every two to three years. Please check back periodically to make
sure that you are using the most current version of the form
Forms differ from state to state depending on local laws and requirements. If you are a patient or
provider outsi