Alaska Do Not Resuscitate Form

Information you will need

• What’s the patient’s first name?
• What’s the patient’s middle name?
• What’s the patient’s last name?
• What month was the patient born?
• What day was the patient born?
• What year was the patient born?
• What’s the patient’s gender?
• What are the patient’s CPR orders?
• What are the patient’s treatment orders?
• What are the patient’s additional orders?
• What are the patient’s nutrition preferences? (optional)
• What’s the representative’s name?
• What’s the representative’s title?
• What’s the provider’s phone number?
• What’s the provider’s name?
• What’s the provider’s license number?
• What’s the patient’s name?
• Was the patient’s advance directive reviewed?
• On what date was the advance directive reviewed?
• Was the patient part of the discussion?
• Was a guardian part of the discussion?
• Was a parent part of the discussion?
• Was a surrogate/agent part of the discussion?
• Was someone else part of the discussion?

…and 18 more fields in the PDF.

Completed by the provider.