Form 1896 "Do Not Resuscitate Order" - Florida

What Is Form 1896?

This is a legal form that was released by the Florida Department of Health - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2004;
  • The latest edition provided by the Florida Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 1896 by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

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Download Form 1896 "Do Not Resuscitate Order" - Florida

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State of Florida
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Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn.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.)
Durable power of attorney (pursuant to Chapter 709, F.S.)
Court appointed guardian
(Applicable Signature)
(Print or Type Name)
PHYSICIAN’S STATEMENT
I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the patient named
above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac
compression, endotracheal intubation and defibrillation) from the patient in the event of the patient’s cardiac or
respiratory arrest.
( _ _ _ ) _ _ _ - _ _ _ _
(Signature of Physician)
(Date)
Telephone Number (Emergency)
(Print or Type Name)
(Physician’s Medical License Number)
DH Form 1896, Revised December 2004
PHYSICIAN’S STATEMENT
State of Florida
DO NOT RESUSCITATE ORDER
I, the undersigned, a physician licensed pursuant to Chapter
458 or 459, F .S., am the physician of the patient named
above. I hereby direct the withholding or withdrawing of
cardiopulmonary resuscitation (artificial ventilation, cardiac
Patient’s Full Legal Name (Print or Type)
(Date)
compression, endotracheal intubation and defibrillation) from
the patient in the event of the patient’s cardiac or respiratory
PATIENT’S STATEMENT
arrest.
Based upon informed consent, I, the undersigned, hereby
direct that CPR be withheld or withdrawn.
(If not signed by patient, check applicable box):
( _ _ _ ) _ _ _ - _ _ _ _
Surrogate
(Signature of Physician)
(Date)
Telephone Number (Emergency)
Proxy (both as defined in Chapter 765, F.S.)
Court appointed guardian
Durable power of attorney (pursuant to Chapter 709, F.S.)
(Print or Type Name)
(Physician’s Medical License Number)
(Applicable Signature)
(Print or Type Name)
DH Form 1896, Revised December 2004
State of Florida
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.)
Durable power of attorney (pursuant to Chapter 709, F.S.)
Court appointed guardian
(Applicable Signature)
(Print or Type Name)
PHYSICIAN’S STATEMENT
I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the patient named
above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac
compression, endotracheal intubation and defibrillation) from the patient in the event of the patient’s cardiac or
respiratory arrest.
( _ _ _ ) _ _ _ - _ _ _ _
(Signature of Physician)
(Date)
Telephone Number (Emergency)
(Print or Type Name)
(Physician’s Medical License Number)
DH Form 1896, Revised December 2004
PHYSICIAN’S STATEMENT
State of Florida
DO NOT RESUSCITATE ORDER
I, the undersigned, a physician licensed pursuant to Chapter
458 or 459, F .S., am the physician of the patient named
above. I hereby direct the withholding or withdrawing of
cardiopulmonary resuscitation (artificial ventilation, cardiac
Patient’s Full Legal Name (Print or Type)
(Date)
compression, endotracheal intubation and defibrillation) from
the patient in the event of the patient’s cardiac or respiratory
PATIENT’S STATEMENT
arrest.
Based upon informed consent, I, the undersigned, hereby
direct that CPR be withheld or withdrawn.
(If not signed by patient, check applicable box):
( _ _ _ ) _ _ _ - _ _ _ _
Surrogate
(Signature of Physician)
(Date)
Telephone Number (Emergency)
Proxy (both as defined in Chapter 765, F.S.)
Court appointed guardian
Durable power of attorney (pursuant to Chapter 709, F.S.)
(Print or Type Name)
(Physician’s Medical License Number)
(Applicable Signature)
(Print or Type Name)
DH Form 1896, Revised December 2004
Estado de Florida ORDEN DE NO RESUCITAR
(por favor, use tinta)
Este lado del formulario está destinado únicamente a la traducción. Los proveedores de Servicios Médicos de Emergencia y el
personal médico sólo deben acatar la versión en inglés del presente formulario. “División de Operaciones Médicas de Emergencia,
Oficina de Traumatología”
Nombre legal completo del paciente:
Fecha:
(Escriba el nombre con letra de imprenta o digítelo)
DECLARACIÓN DEL PACIENTE
Sobre la base del consentimiento informado, yo, quien suscribe, por medio de la presente ordeno que no se me proporcione RCP.
(Si este documento no está firmado por el paciente, marque la casilla pertinente):
Responsable del sujeto
Apoderado (ambos, según se definen en el Capítulo 765 de los Estatutos de Florida)
Tutor designado por el tribunal
Poder de duración indeterminada para fines de atención médica
(de acuerdo con el Capítulo 709 de los Estatutos de Florida)
(Firma correspondiente)
(Escriba el nombre con letra de imprenta o digítelo)
DECLARACIÓN DEL MÉDICO
Yo, quien suscribe, un médico licenciado de acuerdo con el Capítulo 458 ó 459 de los Estatutos de Florida, soy el médico del paciente
anteriormente mencionado. Por medio de la presente, ordeno que no se proporcione resucitación cardiopulmonar (ventilación artificial,
compresión torácica, intubación endotraqueal y desfibrilación) al paciente en caso de que éste sufra un paro cardíaco o respiratorio.
( _ _ _ ) _ _ _ - _ _ _ _
(Firma del médico)
(Fecha)
Número telefónico (Emergencia)
(Escriba el nombre con letra de imprenta o digítelo)
(Número de licencia médica)
FORMULARIO
1896 DEL DEP. DE SALUD, revisado en diciebre de 2004
DECLARACIÓN DEL MÉDICO
Estado de Florida ORDEN DE NO RESUCITAR
Yo, quien suscribe, un médico licenciado de acuerdo con el Capítulo
458 ó 459 de los Estatutos de Florida, soy el médico del paciente
anteriormente mencionado. Por medio de la presente, ordeno que
Nombre legal completo del paciente
(Fecha)
(Escriba con letra de imprenta o digítelo)
no se proporcione resucitación cardiopulmonar (ventilación artificial,
DECLARACIÓN DEL PACIENTE
compresión torácica, intubación endotraqueal y desfibrilación) al
Sobre la base del consentimiento informado, yo, quien suscribe, por medio
paciente en caso de que éste sufra un paro cardíaco o respiratorio.
de la presente ordeno que no se me proporcione RCP. (Si este documento
no está firmado por el paciente, marque la casilla pertinente):
( _ _ _ ) _ _ _ - _ _ _ _
Responsable del sujeto
(Firma del médico)
(Fecha)
Número telefónico (Emergencia)
Apoderado (ambos, según se definen en el Capítulo 765 de los
Estatutos de Florida)
Tutor designado por el tribunal
Poder de duración indeterminada para fines de atención médica (de
(Escriba el nombre con letra de imprenta o digítelo)
(Número de
acuerdo con el Capítulo 709 de los Estatutos de Florida)
licencia médica)
(Firma correspondiente)
(Escriba el nombre con letra de imprenta o digítelo)
FORMULARIO 1896 DEL DEP. DE SALUD, revisado en diciembre de 2004
Eta Laflorid LÒD PA RESISITE
(tanpri itilize lank)
Kote fòm sa a se pou tradiksyon sèlman. Founisè Sèvis Medikal Dijans ak fonksyonè medikal dwe onore vèzyon Anglè fòm sa a.
Divizyon Pou Operasyon Medikal Dijans, Biwo Twoma
Non Legal Konplè pasyan an:
Dat:
(Ekri an Majiskil oswa Tape Non an)
DEKLARASYON PASYAN AN
Baze sou konsantman enfòme an, mwen, ki siyen la, ak prezant sa a deklare pou yo pa fè CPR sou mwen ditou.
(Si pasyan an pat siyen limenm, tcheke kazye ki apwopriye an):
Reprezantan Swen Sante
Pwokirè (tou de jan li dekri nan Chapit 765, F.S.)
Gadyen Tribinal la Chwazi
Responsablite Pwokirasyon Dirab (daprè Chapit 709, F.S.)
(Siyati ki Aplikab)
(Ekri an Majiskil oswa Tape Non an)
DEKLARASYON DOKTÈ AN
Mwen, ki siyen la a, yon doktè sètifye daprè Chapit 458 oswa 459, F.S., mwen doktè pasyan an ki nonmen anwo la. Mwen dirije pou yo kenbe
ak elimine resisitasyon kadyopilmonè (vantilasyon atifisyèl, konpresyon kadyak, endotrakyal entibasyon akdefibrilasyon) pou pasyan an
Sizoka pasyan an ta gen yon epizòd arèdkè oswa respiratwa.
( _ _ _ ) _ _ _ - _ _ _ _
(Siyati Doktè an)
(Dat)
Nimewo Telefòn (Ijans)
(Ekri an Non an Majiskil)
(Nimewo Lisans Medikal Doktè an)
Fòm 1896 DH, Revize Desanm 2004
DEKLARASYON DOKTÈ AN
Eta Laflorid LÒD PA RESISITE
Mwen, ki siyen la a, yon doktè sètifye daprè Chapit 458 oswa 459,
F.S., mwen doktè pasyan an ki nonmen anwo la. Mwen dirije pou yo
kenbe ak elimine resisitasyon kadyopilmonè (vantilasyon atifisyèl,
Non Legal Konplè pasyan an (Ekri an Majiskil oswa Tape)
(Dat)
konpresyon kadyak, endotrakyal entibasyon akdefibrilasyon)
DEKLARASYON PASYAN AN
pou pasyan an sizoka pasyan an ta gen yon epizòd arèdkè oswa
Baze sou enfòmasyon konsanti, mwen, ki siyen la, ak prezant sa a dirije pou
respiratwa.
yo pa fè CPR oswa elimine. (Si pasyan an pat siyen limenm, tcheke kazye
( _ _ _ ) _ _ _ - _ _ _ _
ki apwopriye an):
Reprezantan Swen Sante
(Siyati Doktè an)
(Dat)
Nimewo Telefòn (Ijans)
Pwokirè (tou de fason ki dekri nan Chapit 765, F.S.)
Gadyen Tribinal la Chwazi
Responsablite Pwokirasyon Dirab (daprè Chapit 709,
F.S.) (Ekri an Majiskil oswa Tape Non an) (Nimewo Lisans Medikal Doktè an)
(Siyati ki Aplikab)
(Ekri an Majiskil oswa Tape Non an)
Fòm 1896 DH, Revize Desanm2004
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