Colorado Do Not Resuscitate Form

Information you will need

• What’s the patient’s DOB?
• What’s the patient’s gender?
• What’s the patient’s race?
• What’s the patient’s name?
• What’s the representative’s name?
• What’s the patient’s eye color?
• What’s the patient’s hair color?
• What’s the physician’s name?
• What’s the physician’s address?
• What’s the physician’s phone number?
• What’s the physician’s license number?
• Who signed this form?
• Does the patient consent to tissue donation?
• Does the patient consent to donating all tissues?
• Does the patient consent to donating their skin?
• Does the patient consent to donating their corneas?
• Does the patient consent to donating their musculoskeletal tissue?
• What’s the name of the patient’s hospice program? (if applicable)
• Who is giving the directive?

Completed by the agent and the provider.