Get the free (DNR) Surrogate Consent Form for Persons without Capacity

Resident's Name Resident's Room # FLORENCE NIGHTINGALE HEALTH CENTER SURROGATE IS WRITTEN ORAL CONSENT TO THE ISSUANCE OF A DO NOT RESUSCITATE ORDER Date Resident s ID# I hereby authorize, M.D., to

How to fill out dnr surrogate consent form

How to Fill Out a DNR Surrogate Consent Form:

1. Contact Information: Start by filling in your personal information, including your full name, address, phone number, and email address. This information will be used to identify you as the surrogate decision-maker.
2. Patient Information: Provide the patient's full name, date of birth, and any other identifying details required. Make sure to accurately provide this information as it is crucial for proper identification.
3. Medical Condition: Indicate the patient's current medical condition and any specific details related to their health that may be relevant. This will assist healthcare professionals in making informed decisions regarding the patient's care.
4. Surrogate Decision-Maker: Identify yourself as the surrogate decision-maker by providing your name, relationship to the patient, and contact information. This will establish your authority to make decisions on behalf of the patient when they are unable to do so.
5. Authorization and Consent: Read the provided statements carefully and sign and date the form to indicate that you understand and agree to the terms and conditions. This confirms your consent for medical professionals to follow the specified guidelines in providing or withholding specific treatments for the patient.
6. Witness Signatures: If required, have one or more witnesses sign the form to validate its authenticity. The witnesses should be individuals who are not named as healthcare agents or involved in the decision-making process.

Who Needs a DNR Surrogate Consent Form?

A DNR Surrogate Consent Form is typically needed when a patient is unable to make their own medical decisions due to incapacity or other circumstances. The form is filled out by the surrogate decision-maker, who is usually a close family member or legal representative, and allows them to make healthcare decisions on behalf of the patient. This form ensures that the patient's wishes are respected and provides guidelines to healthcare professionals to follow regarding the patient's care and treatment options. It is recommended for individuals who have specific preferences for end-of-life care or wish to avoid certain medical interventions.

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