Minnesota Do Not Resuscitate (DNR) Order
This Minnesota Do Not Resuscitate (DNR) Order template is designed to provide necessary information
for the creation of an effective DNR order, in compliance with relevant Minnesota state laws,
including the Minnesota Patient’s Bill of Rights. By completing and signing this form, the individual,
or their legally authorized representative, directs medical professionals to withhold resuscitation measures
in the event of cardiac or respiratory arrest.
Complete the following information:
Patient's Full Name: _________________________________________________
Date of Birth: ________________________________________________________
Address: ______________________________________________________________
Primary Physician's Name: _____________________________________________
Physician's Contact Information: ________________________________________
Do Not Resuscitate Order
I, _________________________, understand the full implications of this Do Not Resuscitate Order.
I have discussed my wishes with my physician and understand that this request will guide my medical
team’s actions in the event that my breathing or heart stops. This order is based on my rights under
the Minnesota Patient’s Bill of Rights and my personal wishes.
Date: _________________________
Signature of Patient or Legally Authorized Representative: ___________________
If signed by a legally authorized representative, indicate relationship to patient: ________________________
Physician's Statement
I, _________________________, a licensed physician in the state of Minnesota, attest that the
individual named above has fully discussed their wishes regarding resuscitation with me.
I have advised the individual of the nature, consequences, and risks of this decision, and
certify that this Do Not Resuscitate Order reflects those wishes.
Date: _________________________
Signature of Physician: ____________________________
License Number: ____________________________
Contact Information for Immediate Family or Legal Representative
Please provide contact information for a family member or legal representative to be contacted
in case of an emergency.
Name: _____________________________________________________
Relationship to Patient: _____________________________________
Contact Number: ____________________________________________
Additional Instructions (if any)
_____________________________________________________________________
_____________________________________________________________________