Utah Do Not Resuscitate Form

Information you will need

• What’s the patient’s last name?
• What’s the patient’s first name and middle initial?
• What's the effective date of this order?
• What's the patient's date of birth?
• What's the patient's address?
• What's the medical provider's phone number?
• What's the patient's medical condition?
• What are the patient's goals for medical care?
• What are the patient’s CPR orders?
• What are the patient’s treatment orders?
• What are the patient’s artificial nutrition preferences?
• What's the health care agent's name?
• How strictly is the POLST to be followed?
• Who have these preferences been discussed with?
• What's the name of the person signing this form?
• What's their relationship to the patient?
• What's the medical provider's name?
• What's the second medical provider's name? (if applicable)
• What's the medical provider's license number?
• What's the second medical provider's license number?
• What's the licensed professional's name? (if applicable)
• What's the title of the licensed professional?
• What's the health care agent's phone number?
• What's the LAST FOUR DIGITS of the patient's SIN number?

…and 3 more fields in the PDF.

Completed by the provider.