Blank Do Not Resuscitate Order Template for the State of Minnesota

This Minnesota Do Not Resuscitate (DNR) Order template is designed to comply with the specific statutes of the state of Minnesota. It allows individuals to make informed decisions about their end-of-life care, ensuring their wishes are respected.

Complete the following information to create a valid DNR Order in Minnesota:

1. Full Name of the Individual (Patient): ____________________________
2. Date of Birth: ____________________________
3. Address: ____________________________
4. Primary Physician: ____________________________
5. Physician's Contact Information: ____________________________
6. Patient's Signature: ____________________________
7. Date: ____________________________
8. Witness Signature: ____________________________
9. Witness Name (Printed): ____________________________
10. Date: ____________________________
11. Physician's Signature: ____________________________
12. Date: ____________________________

By signing this document, the patient acknowledges their understanding and desire not to receive cardiopulmonary resuscitation (CPR) in the event that their breathing stops or if their heart ceases beating. This decision is made in accordance with Minnesota state-specific laws and is binding across healthcare settings within the state.

It is recommended that this document is reviewed regularly and kept in a location where it can be easily accessed by healthcare providers, family members, or caregivers. For more comprehensive planning, consider consulting with a healthcare provider or legal professional.