Printable Do Not Resuscitate Order Document for Indiana

This Indiana Do Not Resuscitate (DNR) Order is in accordance with the guidelines set forth under the relevant Indiana state laws, including the Indiana Code 16-36-6 (Patient Preferences Act). It serves as a directive for healthcare providers relating to the administration of life-sustaining treatments to the individual named herein.

Personal Information of the Individual:

• Full Name: _________________________________________
• Date of Birth: _______________________________________
• Address: ____________________________________________
• City, State, ZIP: ____________________________________

Emergency Contact Information:

• Name: ______________________________________________
• Relationship to Individual: ___________________________
• Phone Number: ______________________________________

Physician Information:

• Physician's Name: ___________________________________
• Physician's License Number: __________________________
• Address: ____________________________________________
• Phone Number: ______________________________________

This document reflects the individual's decision to forego resuscitation in the event of cardiac or respiratory arrest. This decision has been made after careful consideration, understanding all potential consequences, and in consultation with a licensed physician.

A valid DNR order must be signed and dated by:

1. The individual, or their legally authorized representative, if the individual is unable to sign due to physical incapacity.
2. The individual's attending physician, who acknowledges the individual's decision to forgo resuscitative efforts.

Signature of Individual or Representative:

___________________________________________________

Date: _______________________________________________

Signature of Attending Physician:

___________________________________________________

Date: _______________________________________________

This DNR Order is valid unless revoked by the individual. It is the responsibility of the individual or their representative to notify and provide a copy of this DNR order to other healthcare providers as necessary.

Note: Always consult with a healthcare professional or legal advisor to ensure that this document meets your specific needs and complies with current Indiana laws. This template is intended for informational purposes only and does not substitute for professional advice.