Fillable Do Not Resuscitate Order Form for Utah State Access Editor

Fillable Do Not Resuscitate Order Form for Utah State

A Do Not Resuscitate (DNR) Order form in Utah allows individuals to express their wishes regarding resuscitation efforts in the event of a medical emergency. This legal document ensures that healthcare providers respect a patient's decision to forgo life-saving measures. Understanding and completing this form is crucial for those who wish to communicate their end-of-life preferences clearly.

To take the next step in expressing your healthcare wishes, please fill out the form by clicking the button below.

The Utah Do Not Resuscitate Order form serves as a crucial document for individuals who wish to express their preferences regarding medical interventions in emergency situations. This form is designed to communicate a person's desire not to receive cardiopulmonary resuscitation (CPR) or other life-sustaining treatments in the event of a medical crisis. It is important for patients, families, and healthcare providers to understand the implications of this order, as it ensures that a person's wishes are respected during critical moments. The form requires specific information, including the patient's name, date of birth, and signature, as well as the signatures of witnesses or a healthcare provider. Additionally, it must be readily available to medical personnel to be honored effectively. Understanding the nuances of the Utah Do Not Resuscitate Order form can empower individuals to make informed decisions about their healthcare preferences, fostering a sense of control during challenging times.

Sample - Utah Do Not Resuscitate Order Form

Utah Do Not Resuscitate (DNR) Order Template

This document serves as a Do Not Resuscitate (DNR) Order, in compliance with the relevant Utah state laws, specifically the Utah Uniform Patient Rights Act. It is designed to inform medical professionals about the decision of an individual not to receive cardiopulmonary resuscitation (CPR) in the event that their breathing stops or their heart stops beating.

Patient Information:

  • Full Name: _______________________________
  • Date of Birth: ___________________________
  • Address: __________________________________
  • City: _____________________________________
  • State: Utah
  • Zip Code: ________________________________
  • Primary Phone: ____________________________

Medical Professional or Health Care Agent Information:

  • Full Name: _______________________________
  • Qualification/Relation: ____________________
  • Contact Number: ___________________________

This DNR Order reflects the explicit wishes of the undersigned patient, or their legally authorized representative, not to have cardiopulmonary resuscitation (CPR) initiated in the cases of cardiac or respiratory arrest.

This declaration is made after careful consideration and is in accordance with the patient's rights and preferences. It is intended to guide medical personnel in delivering care that aligns with the patient's wishes.

Signature Section:

  1. Patient or Legally Authorized Representative Signature: _________________________
  2. Date: ________________________________________
  3. Physician Signature (Optional in Utah, but recommended): ________________________
  4. Date: ________________________________________
  5. Witness Signature: ____________________________________
  6. Date: ________________________________________

This DNR Order is valid throughout the state of Utah. It is recommended that this document be reviewed regularly and kept in a place where it can be easily accessed by family members and medical professionals.

Notice: A Do Not Resuscitate Order is a legal document that affects your medical treatment. It is strongly recommended that you discuss your wishes with your family, legal representative, and healthcare providers.

Form Attributes

Fact Name Details
Governing Law The Utah Do Not Resuscitate Order is governed by Utah Code Title 26, Chapter 28.
Purpose This form allows individuals to express their wishes regarding resuscitation efforts in the event of a medical emergency.
Eligibility Any adult who is capable of making healthcare decisions can complete the form.
Signature Requirement The form must be signed by the individual or a legally authorized representative.
Healthcare Provider's Role Healthcare providers are required to honor the Do Not Resuscitate Order once it is properly completed and signed.
Revocation The order can be revoked at any time by the individual or their representative.
Availability The Utah Do Not Resuscitate Order form is available through healthcare providers and state health department resources.
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