Washington Do Not Resuscitate Order Form

Information you will need

• What year was the patient born?
• What's the patient's gender? (optional)
• What are the patient's pronouns? (optional)
• What's the patient’s medical condition and what are their goals?
• What's the agency information and phone number? (if applicable)
• What are the patient’s CPR orders?
• What are the patient’s treatment orders?
• What are the patient’s additional orders?
• Was a parent part of the discussion?
• Was a guardian with health care authority part of the discussion?
• What’s the health care provider’s name?
• What’s their relationship to the patient?
• What's the patient's/legal decision maker's full name?
• What’s the provider’s phone number?
• What’s the phone number?
• Does the patient have an advance directive or living will?
• What month was the patient born?
• What day was the patient born?
• What’s the name of the legal decision maker? (if applicable)
• What’s the relationship of the legal decision maker to the patient?
• What’s the phone number of the legal decision maker?
• What’s the name of the other contact person? (if applicable)
• What’s the relationship of the other contact person to the patient?
• What’s the other contact person’s phone number?

…and 17 more fields in the PDF.

Completed by the agent and the provider.

The form includes a witness section.