Do Not Resuscitate / Do Not Intubate Consent Form
Use this form to record a patient's preferences about resuscitation and intubation, along with contact and attestation details.
Patient Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Contact Number or Email
*
Decision Maker and Emergency Contact
Decision Maker Name
First Name
Middle Name
Last Name
Relationship to Patient
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
No Decision Maker Appointed
Not appointed
Resuscitation and Intubation Preferences
Do Not Resuscitate (DNR) preference
*
Full resuscitation
Do Not resuscitate
Allow natural death
Other
Do Not Intubate (DNI) preference
*
Intubation permitted
Do not intubate
Only if medically necessary
Other
Temporary ventilation acceptable if needed
Yes, if reversible and short-term
No, not acceptable
Only after discussing with my care team
Other
Attestation and Signature
Signature of Patient or Authorized Decision-Maker
*
Submit Form
Submit Form
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