New Hampshire Do Not Resuscitate (DNR) Order Template
This document serves as a directive under the laws of New Hampshire for those wishing to have a Do Not Resuscitate (DNR) Order. A DNR order is a medical order that must be written by a physician or authorized healthcare provider, indicating that cardiopulmonary resuscitation (CPR) should not be attempted if a patient's breathing stops or if the patient's heart stops beating. This template is intended to guide the information required to complete a DNR order pursuant to relevant state-specific laws, particularly those found within the New Hampshire Patient Determination and Qualifying Conditions.
Personal Information
Patient's Name: ___________________________________________________
Patient's Date of Birth: ___________________________________________
Patient's Address: ______________________________________________
______________________________________________
Phone Number: ____________________________________________________
Medical Information
Primary Physician's Name: __________________________________________
Primary Physician's Contact Information: ____________________________
______________________________________________
Medical Facility (if applicable): ___________________________________
DNR Order Directive
I, _________________________ (Patient's Name), hereby direct that no resuscitation efforts, including CPR, be attempted on my behalf and understand the full implications of this order. This decision is made voluntarily and after thorough consideration of all possible outcomes. This document is supported by the New Hampshire State-specific provisions relating to patient self-determination and DNR orders.
This DNR order is to remain in effect until it is revoked. I understand that I have the right to revoke this order at any time.
Signature
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Patient's Signature
________________________________
Date
If the patient is unable to sign, a legal representative may sign on behalf of the patient:
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Representative's Name
________________________________
Representative's Relationship to Patient
________________________________
Representative's Signature
________________________________
Date
Physician's Section
The undersigned physician affirms that the above-named patient has discussed and elected a DNR order. This order is consistent with the patient's medical condition and desires.
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Physician's Name
________________________________
License Number
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Physician's Signature
________________________________
Date
Witness Section
This DNR order has been signed in the presence of the following witnesses, confirming that the patient, or their representative, has signed or acknowledged their signature on this document willingly and voluntarily.
- Witness 1 Name: __________________________________________
- Witness 2 Name: __________________________________________
Signature of Witness 1: _______________________________________
Date: ________________________________________________________
Signature of Witness 2: _______________________________________
Date: ________________________________________________________
