This Georgia Do Not Resuscitate (DNR) Order Template is designed to inform medical professionals that the individual named below has decided against attempts of resuscitation in the event that their breathing or heart stops. This decision is made under the regulation of Georgia state-specific laws, including the Georgia Advance Directive for Health Care Act.
Personal Information:
- Full Name: ___________________________
- Birth Date: ___________________________
- Address: ______________________________
- City: _________________________________
- State: Georgia
- ZIP Code: ____________________________
- Phone Number: _________________________
Designated Health Care Agent (If applicable):
- Agent's Full Name: ___________________________
- Relationship to Patient: ___________________
- Phone Number: ______________________________
- Alternate Phone Number: ____________________
This document serves as a legal order, in accordance with Georgia laws, specifically the Georgia Advance Directive for Health Care Act, to not initiate cardiopulmonary resuscitation (CPR) in the event the person’s heart and/or breathing stops. This applies to health care settings including, but not limited to, hospitals, nursing homes, and during emergency medical services (EMS) care.
Medical Professional's Verification:
This section is to be completed by a licensed healthcare provider who verifies that the patient understands the full extent of their decision and that this Do Not Resuscitate Order is consistent with the patient's current medical condition and desired level of care.
- Physician's/Provider's Name: ___________________________
- License Number: ____________________________________
- Phone Number: ______________________________________
- Date: _______________________________________________
- Signature: __________________________________________
Patient's or Legally Authorized Representative's Acknowledgment:
This section acknowledges that the decision for a Do Not Resuscitate Order has been made by the patient or their legally authorized representative, after being fully informed of the nature, consequences, and alternatives to a DNR order. This decision is voluntary and without any form of pressure or coercion.
- Patient or Representative's Name: ______________________________
- Relationship to Patient (if not the patient): ___________________
- Date: ________________________________________________________
- Signature: ____________________________________________________
Note: This form does not invalidate any other advance directives, living wills, or health care powers of attorney that the patient may have already established. It solely relates to the patient's request for not undergoing CPR in circumstances of cardiac or respiratory arrest.