Blank Wyoming Do Not Resuscitate Order Form

Wyoming Do Not Resuscitate (DNR) Order Template

This document serves as a Do Not Resuscitate (DNR) Order, following the guidelines established by Wyoming state laws. It is specifically designed to inform medical professionals of the patient's wish not to receive cardiopulmonary resuscitation (CPR) in the event that their breathing stops or their heart ceases to beat.

This order should be completed by the patient or their legally authorized representative, in collaboration with a licensed healthcare provider. Please ensure that all sections are filled accurately to reflect the patient's wishes effectively.

Patient Information

Patient Name: ___________________________________________________

Address: _______________________________________________________

Date of Birth: _________________________

Wyoming Identification Number: _________________________________

Medical Professional Information

Healthcare Provider Name: ________________________________________

Title: _________________________________________________________

Address: _______________________________________________________

Contact Number: ________________________________________________

DNR Order Declaration

By my signature below, I, or my legally authorized representative, in accordance with Wyoming state laws, hereby declare my wish to forego cardiopulmonary resuscitation (CPR) in the event that my breathing stops or my heart ceases to beat. This order is to be followed by all health care providers and emergency medical personnel.

Signature

Patient or Legally Authorized Representative Signature: ________________________________

Date: ______________________

Healthcare Provider Signature: _________________________________

Date: ______________________

Important Information

• This DNR Order is valid only in the State of Wyoming.
• This document should be kept in a location where it can be easily accessed by emergency personnel.
• The patient or their representative may cancel this order at any time by destroying this document and informing their healthcare provider.
• A new DNR Order must be completed if the patient revokes the previous one and wishes to reinstate the order at a later date.

For more information on the legal implications and the specific details of executing a Do Not Resuscitate Order in Wyoming, please consult with a healthcare provider or legal professional.