Nevada Do Not Resuscitate Form

Information you will need

• What’s the patient’s gender?
• What are the patient’s CPR orders?
• What’s the health care provider's license number?
• What’s the health care provider's phone number?
• What are the last four digits of the patient's SSN?
• What’s the patient’s birth month?
• What’s the patient’s birth day?
• What’s the patient’s birth year?
• What’s the patient’s EMS DNR number?
• What are the patient’s medical intervention orders?
• Are there additional instructions regarding full life support interventions?
• Are there additional instructions regarding selective medical interventions?
• What are the patient's preferences regarding artificial nutrition and fluids?
• How long may artificial nutrition and fluids be administered?
• How long may IV fluids be administered?
• Are there additional instructions regarding comfort focused treatment?
• Are there additional instructions regarding artificial nutrition and fluids?
• What’s the name of the health care provider?
• What’s the patient’s name?
• What’s the patient’s DOB?
• Does the patient have an advance directive?
• Is the advance directive filed with Living Will Lockbox?
• What’s the Living Will Lockbox registration number?
• Does the patient have a court appointed guardian?

…and 15 more fields in the PDF.

Completed by the provider and the agent.

The form includes 2 signature lines.