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Official Do Not Resuscitate Order Template for the State of Virginia

A Virginia Do Not Resuscitate Order (DNR) form is a legal document that allows individuals to express their wishes regarding medical treatment in the event of a cardiac arrest or respiratory failure. This form ensures that healthcare providers respect a person's decision not to receive resuscitation efforts. Understanding the implications of this order is crucial for anyone considering it for themselves or a loved one.

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Similar forms

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Document Sample

Virginia Do Not Resuscitate Order

This document serves as a formal declaration of the desire not to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest, in accordance with Virginia state laws.

This Do Not Resuscitate (DNR) Order is intended for the following individual:

Full Name: ___________________________________________
Date of Birth: ______________________________________
Address: ___________________________________________
City, State, Zip Code: ____________________________

The individual listed above wishes to decline resuscitative efforts under the following circumstances:

Cardiac arrest
Respiratory arrest

In making this choice, the individual acknowledges the following:

This decision is made voluntarily and reflects my wishes.
Medical professionals will honor this order during a medical emergency.
This document may be revoked at any time by notifying healthcare providers.

This order is valid only if it is signed and dated by the individual (or appointed agent) declaring this choice:

Signature of Declarant/Agent: ___________________________
Date: _______________________________________________

Witnesses are required to ensure that this Do Not Resuscitate Order is respected. Below are the spaces for witnesses to sign:

Witness 1 Name: ___________________ Signature: _____________________
Date: _______________________________

Witness 2 Name: ___________________ Signature: _____________________
Date: _______________________________

Remember to keep a copy of this document in a readily accessible location and provide copies to your healthcare providers, family members, and legal representative.

Download Do Not Resuscitate Order PDF

Key takeaways

When considering a Do Not Resuscitate (DNR) Order in Virginia, it is essential to understand the implications and processes involved. Here are key takeaways to keep in mind:

The DNR Order is a legal document that instructs medical personnel not to perform cardiopulmonary resuscitation (CPR) in the event of cardiac arrest.
It is crucial to have a conversation with your healthcare provider before completing the form. This ensures that your wishes are clear and understood.
The form must be signed by both the patient (or their legal representative) and a licensed physician to be valid.
Once completed, the DNR Order should be kept in a prominent place, such as on the refrigerator or with other important medical documents, so it is easily accessible during emergencies.
It is important to review and update the DNR Order periodically, especially if there are changes in health status or personal preferences.
Family members should be informed about the existence of the DNR Order and its implications to avoid confusion during critical moments.

Other Common State-specific Do Not Resuscitate Order Templates

How Old Do You Have to Be to Get a Dnr - Essential for those with clear preferences about resuscitation efforts.

Dnr Directive - Notifies emergency responders of the patient's wishes before they arrive on the scene.

To further facilitate the process of transferring ownership, individuals can utilize resources such as Fillable Forms, which provide accessible templates for creating a comprehensive Motor Vehicle Bill of Sale that ensures all necessary information is included and clearly documented.

Dnr Document - It is advisable to keep a copy of the DNR order in an accessible location, like a medical file or with a caregiver.

Instructions on How to Fill Out Virginia Do Not Resuscitate Order

Completing the Virginia Do Not Resuscitate Order form requires careful attention to detail. This document is essential for expressing a person's wishes regarding resuscitation efforts in medical emergencies. Follow these steps to ensure the form is filled out correctly.

Obtain the Virginia Do Not Resuscitate Order form. This can be downloaded from the Virginia Department of Health website or obtained from a healthcare provider.
Fill in the patient’s full name at the top of the form.
Provide the patient’s date of birth. This helps to confirm their identity.
Indicate the patient's address. Include the street, city, state, and zip code.
Check the appropriate box to indicate whether the patient is an adult or a minor.
Have the patient or their legal representative sign the form. This signature confirms that they understand and agree to the contents of the form.
Include the date of the signature. This is important for record-keeping purposes.
Ensure that the form is witnessed by two individuals. They should also sign and date the form to validate it.
Make copies of the completed form. Keep one for personal records and provide copies to healthcare providers involved in the patient's care.

Once the form is completed, it is crucial to communicate its existence to family members and healthcare providers. This ensures that everyone involved is aware of the patient's wishes in case of a medical emergency.