South Carolina Do Not Resuscitate (DNR) Order FormSouth Carolina Do Not Resuscitate (DNR) Order Form
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Emergency Medical Services
Do Not Resuscitate Order

SOUTH CAROLINA
EMERGENCY MEDICAL SERVICES

RESUSCITATE

DO NOT RESUSCITATE ORDER

NOTICE TO EMS PERSONNEL
This notice is to inform all emergency medical personnel who may be called to render assistance to
(Name of Patient)

that he/she has a terminal condition which has been diagnosed by me and is at

least eighteen (18) years of age, and has specifically requested that no resuscitative efforts including artificial stimulation
of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardiopulmonary
arrest.

REVOCATION PROCEDURE
THIS FORM MAY BE REVOKED BY AN ORAL STATEMENT BY THE PATIENT TO EMS PERSONNEL, OR BY
MUTILATING, OBLITERATING, OR DESTROYING THE DOCUMENT IN ANY MANNER.
Date

Patient's Signature (or Surrogate or Agent)

Physician's Name (Please Print)

Physician's Signature

Physician's Address

Physician's Telephone Number

DHEC 3462 (06/2015)

SOUTH CAROLINA DEPART