Free New Mexico Do Not Resuscitate Order Form

New Mexico Do Not Resuscitate Order

This document serves as a Do Not Resuscitate (DNR) Order in accordance with the New Mexico Uniform Health-Care Decisions Act (NMUHCDA). It is a legal document that indicates the individual's wish not to receive cardiopulmonary resuscitation (CPR) in the event the heart stops or if breathing ceases. This document must be completed by the individual or their legally authorized representative and the attending physician to be valid.

Please fill in the required information in the spaces provided:

Patient Information:

• Patient's Full Name: ___________________________
• Date of Birth (MM/DD/YYYY): _____________________
• Address: _______________________________________
• City: ___________________ State: NM Zip: __________

Legal Representative Information (if applicable):

• Representative's Full Name: ________________________
• Relationship to Patient: ___________________________
• Contact Number: _________________________________

Physician Information:

• Physician's Full Name: ____________________________
• License Number: __________________________________
• Contact Number: _________________________________

Order Statement:

I, ___________ [Patient's Full Name] _____________, or my legally authorized representative, request that in the event my heart should stop or if I should stop breathing, no cardiopulmonary resuscitation (CPR) should be performed on me. I understand the full implications of this order and make it voluntarily.

Signature Section:

Patient or Legally Authorized Representative Signature: ________________ Date: ____________

Physician Signature: ________________________________________________ Date: ____________

Instructions for Healthcare Providers:

Healthcare providers must comply with this legally binding order unless revoked by the patient or their legally authorized representative. This document should be kept in a prominent location within the patient's medical records. In the case of transfer to another care facility, the DNR order must accompany the patient.

Revocation:

The individual or their legally authorized representative may revoke this order at any time by informing the attending physician or healthcare provider either verbally or in writing.