Do Not Resuscitate Order Template for Rhode Island State

Rhode Island Do Not Resuscitate (DNR) Order Template

This document serves as a Do Not Resuscitate Order, in accordance with the specific provisions outlined in the Rhode Island Right to Try Act. It has been created to respect the wishes of individuals who choose not to undergo cardiopulmonary resuscitation (CPR) in the event that their breathing or heart stops. This order is valid only within the state of Rhode Island.

Personal Information:

• Full Name: ___________________________________________
• Date of Birth: ________________________________________
• Address: ______________________________________________
• City, State, Zip: ______________________________________
• Phone Number: _________________________________________

Emergency Contact Information:

• Full Name: ___________________________________________
• Relationship: _________________________________________
• Phone Number: _________________________________________
• Alternate Phone Number: _______________________________

Do Not Resuscitate (DNR) Order Declaration:

I, ___________________________, being of sound mind, hereby direct that no resuscitation efforts, including but not limited to CPR, be performed on me. This declaration is valid throughout the state of Rhode Island and will remain in effect unless I revoke it through a written notice. My decision is based on personal beliefs and an understanding of my medical condition. This order is made voluntarily and without any external pressure.

Physician Information:

• Physician's Full Name: __________________________________
• License Number: ________________________________________
• Address: _______________________________________________
• Phone Number: __________________________________________

By signing this document, I acknowledge that I have been fully informed of the nature and effect of a Do Not Resuscitate Order. I understand that this means if my heart stops beating or if I stop breathing, no medical intervention will be initiated to save my life.

Signature of the Principal: _________________________________
Date: _______________________________________________________

Witness Declaration:

I, ______________________, declare that the individual signing this document is known to me, and they appeared to be of sound mind and under no duress or undue influence at the time of signing.

Signature of Witness: ______________________________________
Date: _______________________________________________________

Physician's Acknowledgment:

I, ________________________, hereby acknowledge that I have discussed the implications of the Do Not Resuscitate Order with the above-named individual and confirm that they are fully aware of its significance.

Signature of Physician: ____________________________________
License Number: _____________________________________________
Date: _______________________________________________________