APA assignment

State of Florida DO NOT RESUSCITATE ORDER

(please use ink)

Patient’s Full Legal Name: ________________________________________________Date:____________________ (Print or Type Name)

PATIENT’S STATEMENT Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn.

(If not signed by patient, check applicable box):

q Surrogate q Proxy (both as defined in Chapter 765, F.S.) q Court appointed guardian q Durable power of attorney (pursuant to Chapter 709, F.S.)

________________________________________________________________________________________________ (Applicable Signature) (Print or Type Name)

PHYSICIAN’S STATEMENT I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient’s cardiac or respiratory arrest.

________________________________________________________________________________________________ (Signature of Physician) (Date) Telephone Number (Emergency)

________________________________________________________________________________________________ (Print or Type Name) (Physician’s Medical License Number)

DH Form 1896, Revised December 2002

PHYSICIAN’S STATEMENT

I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient's cardiac or respiratory arrest.

________________________________________________________ (Signature of Physician) (Date) Telephone Number (Emergency)

________________________________________________________ (Print or Type Name) (Physician’s Medical License Number)

DH Form 1896,Revised December 2002

State of Florida DO NOT RESUSCITATE ORDER

________________________________________________________________ Patient’s Full Legal Name (Print or Type) (Date)

PATIENT’S STATEMENT Based upon informed consent, I , the unders i g n e d ,h e r e by direct that CPR be withheld or withdrawn. (If not signed by patient, check applicable box): q Surrogate q Proxy (both as defined in Chapter 765, F.S.) q Court appointed guardian q Durable power of attorney (pursuant to Chapter 709, F.S.)

________________________________________________________________ (Applicable Signature) (Print or Type Name)