State of Florida DO NOT RESUSCITATE ORDER
DO NOT RESUSCITATE ORDER (please use ink) Patient’s Full Legal Name: Date: (Print or Type Name) PATIENT’S STATEMENT Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn. (If not signed by patient, check applicable box): Surrogate Proxy (both as defined in Chapter 765, F.S.)
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State of Florida DO NOT RESUSCITATE ORDER
www.floridahealth.govState of Florida DO NOT RESUSCITATE ORDER (please use ink) Patient’s Full Legal Name: Date: (Print or Type Name) PATIENT’S STATEMENT
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