Attorney-Approved Do Not Resuscitate Order Form for Alabama

Alabama Do Not Resuscitate (DNR) Order

This document serves as a Do Not Resuscitate (DNR) Order in accordance with the Alabama Department of Public Health's guidelines under the Alabama Code. It is a legally binding order indicating that a person does not want to be revived through cardiopulmonary resuscitation (CPR) in the event their breathing stops or if their heart stops beating.

Personal Information:

• Name: ___________________________________________
• Date of Birth: ___________________________________
• Address: _________________________________________
• City: ______________________, State: Alabama
• Zip Code: ________________________________________
• Phone Number: ____________________________________

Medical Information:

• Primary Physician: ________________________________
• Physician's Phone Number: __________________________
• Medical Conditions/Diagnosis: ________________________

This DNR Order reflects the express wishes of the individual named herein or their legally authorized representative. It directs health care providers and emergency personnel not to attempt cardiopulmonary resuscitation (CPR), including but not limited to mechanical ventilation, defibrillation, and the use of advanced airway management techniques.

The effectiveness of this DNR Order depends on its presentation to the health care provider, emergency medical personnel, or hospital. It is recommended that this document and any other relevant advance directive documents be easily accessible in the event of an emergency.

Directive:

I, ____________________ (the "Patient"), hereby declare that I do not wish to receive cardiopulmonary resuscitation (CPR) in the event my heart stops beating or if I stop breathing. This decision is made after careful consideration and consultation with my healthcare provider, ________________________ (Name of Healthcare Provider), whose opinions and advice have been considered in making this decision.

Signature of Patient or Legally Authorized Representative:

______________________________________ Date: ________________

Witness Declaration:

I, ____________________ (Name of Witness), declare that the individual signing this document appears to be of sound mind and free from duress at the time of signing, and that they affirmatively stated that they are fully informed regarding the nature and consequence of this DNR Order.

Signature of Witness:

______________________________________ Date: ________________

Physician's Agreement:

I, ____________________ (Name of Physician), affirm that I have discussed the implications and the nature of a Do Not Resuscitate Order with the Patient and/or their legally authorized representative. I concur with the Patient's decision not to receive CPR as specified in this document.

Signature of Physician:

______________________________________ Date: ________________

This document should be reviewed periodically and may be revoked by the Patient or their legally authorized representative at any time. Always consult with a healthcare provider for any changes in the patient's health condition or wishes regarding resuscitation efforts.