Maine Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order template is designed to help you communicate your wishes regarding resuscitation in the state of Maine. It is important to complete this document accurately to ensure that your preferences are honored in a medical emergency.
Patient Information:
- Name: ________________________________________
- Date of Birth: _______________________________
- Address: ______________________________________
- City: _____________________ State: ___ Zip: _________
- Patient's Physician: _____________________________
- Phone Number: ________________________________
DNR Statement:
I, the undersigned, hereby declare that I do not wish to receive resuscitation measures in the event of a cardiac or respiratory arrest. This decision has been made after discussing my options with my physician.
Signature of Patient: _____________________________________
Date: ________________________________________
Witness Information:
- Witness Name: ______________________________________
- Address: ___________________________________________
- City: _____________________ State: ___ Zip: __________
- Phone Number: ____________________________________
By signing this document, the witness confirms that the patient was of sound mind while making this decision.
Important Notes:
- This DNR Order is effective immediately upon signing.
- Make copies of this order and share them with your family and healthcare providers.
- Keep the original document in a safe but accessible place.
If you have any questions or need help filling out this DNR Order, consider reaching out to a healthcare professional or legal advisor.