DSHS Do Not Resuscitate Forms

 

The Texas Department of State Health Services (DSHS) maintains a page with forms for use in the Out-of-Hospital Do-Not-Resuscitate program. The program allows people to decide that they do not want to be resuscitated. It allows people to declare that certain resuscitative measures will not be used on them. Those resuscitative measures specifically listed in the law are cardiopulmonary resuscitation (CPR), advanced airway management, defibrillation, artificial ventilations, and transcutaneous cardiac pacing.

Download the form.

 

Forms can also be ordered from the Texas Medical Association at:
Texas Medical Association
ATTN: DNR form
401 West 15th Street
Austin, Texas 78701-1680

Bracelets (vinyl) cost: $1.60 plus tax $.13 = $1.73 (Note: these bracelets are generic - i.e. they do not come personalized)

Form: $.20 plus tax $.02 = $.22

Together: $1.80 plus tax $.15 =  $1.95


Specifications regarding the Out of Hospital Do-Not-Resuscitate (OOH DNR) form:.

  • The OOH DNR Order form is on standard letter-size paper, 8 1/2 inches by 11 inches.
  • The form can be copied and used as an original.
  • The form should be printed with the OOH DNR Order form on the front and the instructions on the back of the sheet.
  • Copies of an executed DSHS Standard OOH DNR Order can be made and are legal, binding documents.

 

Last Updated On

May 20, 2016

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