Free Alaska Do Not Resuscitate Order Form

This Alaska Do Not Resuscitate (DNR) Order is intended for patients who wish not to have cardiopulmonary resuscitation (CPR) in the event their breathing stops or their heart ceases to beat. This document is to be completed in accordance with the Alaska Statutes Title 13. Health, Safety, Housing, Human Rights, and Public Defender, specifically sections pertinent to health care directives and patients’ rights regarding end-of-life decisions.

Personal Information:

• Patient Name: ________________________________________
• Date of Birth: ________________________________________
• Address: ______________________________________________
• City, State, Zip: ______________________________________
• Telephone Number: _____________________________________

Medical Information:

• Primary Physician Name: ________________________________
• Primary Physician Telephone Number: _____________________

Order Information:

I, ________________________ (the "Patient"), hereby direct that no resuscitative measures, including CPR, be initiated or continued if my breathing and heartbeat cease. This decision has been made after careful consideration and is consistent with my right to refuse medical treatment under Alaska state laws.

This DNR order is to remain in effect until revoked. I understand that I may revoke this order at any time by destroying this document and all copies or by informing my attending physician or healthcare provider verbally or in writing.

Witness Statement:

I, ________________________ (the "Witness"), declare that the Patient has voluntarily signed this document in my presence and appears to be of sound mind and under no duress, fraud, or undue influence.

Signatures:

Patient Signature: _________________________________ Date: _____________

Witness Signature: _________________________________ Date: _____________