Texas Do Not Resuscitate Form

Information you will need

• What's the person's gender?
• What’s the person's full name?
• What's the representative's full name? (if applicable)
• What's the qualified relative's full name? (if applicable)
• What's the physician's printed name? (if applicable)
• What's the parent, guardian, or conservator's name? (if applicable)
• What's the name of the first witness?
• What's the name of the second witness?
• What's the person's date of birth?
• What’s the full name of the person making their own declaration?
• What qualified relative is making this declaration? (if applicable)
• Print Form
• Is the declaration being done by a guardian, agent, or proxy? (if applicable)
• Is the declaration being done by physician based on a directive?
• What's the physician's license number?
• What guardian is making this declaration on behalf of the minor? (if applicable)
• County (Notary Only)
• Name (Notary Only)
• What's the physician's name?
• What's the first physician's printed name? (if applicable)
• What's the second physician's printed name? (if applicable)
• What's the first physician's license number? (if applicable)
• What's the second physician's license number? (if applicable)

Completed by the agent and the employee and the declarant.

The form includes 15 signature lines, a notary acknowledgment, a witness section.

The document text refers to the laws of Texas.