MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH 
OFFICE OF EMERGENCY MEDICAL SERVICES

COMFORT CARE / DO NOT RESUSCITATE
(“DNR”) ORDER VERIFICATION
	CCFORM_INSERT 2/2007

PATIENT’S LAST NAME		
     		
PATIENT’S FIRST NAME		PATIENT’S MIDDLE NAME OR INITIAL
PATIENT’S LAST NAME	
AAAAAA	

     		     	
DATE OF BIRTH (MM/DD/YYYY)		GENDER		
     			M		F		
	
STREET OR RESIDENTIAL ADDRESS	
     	
CITY	STATE	ZIP CODE (5 or 9 digits)	
     	  	     	—	    	
	
LAST NAME OF GUARDIAN OR HEALTH CARE AGENT (If applicable)	
     	
FIRST NAME OF GUARDIAN OR HEALTH CARE AGENT		MIDDLE NAME OR INITIAL
PATIENT’S LAST NAME	
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PATIENT/GUARDIAN/HHEALTH CARE AGENT STATEMENT (SIGNATURE AND DATE REQUIRED)		
I	     	(patient    guardian   health care agent) 		
verify that the above named patient has a current and valid Do Not Resuscitate order (“DNR order”). I understand that by signing this form, the DNR order, if current and valid, will be recognized in out-of-hospital settings and the COMFORT CARE / Do Not Resuscitate Order Verification Protocol will be followed by emergency medical services personnel.		
		     		
Signature of Patient/Guardian/Health Care Agent		Date		
	
PHYSICIAN / NURSE PRACTICIONER (NP) / PHYSICIAN ASSISTANT (PA) VERIFICATION (PHYSICIAN / NP / PA SIGNATURE AND DATES ALWAYS REQUIRED)	
I am an attending physician / NP / PA for the above named patient. I verify that the above named patient has a current and valid Do Not Resuscitate  	
order, issued on	     		
			
This DNR order 	 	 does	 	does not	have an expiration date.  If there is an expiration date, it is indicated below, and this 	
verification form also expires on that date.	
I hereby direct that all emergency medical services personnel comply with the Massachusetts Department of Public Health, Office of Emergency Medical Services’ COMFORT CARE / Do Not Resuscitate Order Verification Protocol with regard to the above named patient.	
	
Signature of Physician / NP / PA		
Print Name of Physician / NP / PA	Effective Date of CC / DNR Order Verification	Expiration Date (if any) of DNR Order and CC/DNR Order Verification	
     		     		     	
Address of Physician / NP / PA	
     	
Telephone Number of Physician / NP / PA	
     	
OPTIONAL BRACELET INSERTS	
Attention Physician/NP/PA	Pat. Name	     	Gender         M     F	
If used, enter information or print legibly. Physician/NP/ PA must sign, tear off strip, fold, trim, and insert in bracelet.
Massachusetts	Pat. DOB:	     	Expir. Date:	     	Tel.	   -   -    	
	MD/NP/PA 	     	Signature		
Comfort Care/DNR Order Verification					
Attention Physician/NP/PA	Pat. Name	     	Gender         M     F	
If used, enter information or print legibly. Physician/NP/ PA must sign, tear off strip, fold, trim, and insert in bracelet.
Massachusetts	Pat. DOB:	     	Expir. Date:	     	Tel.	   -   -    	
	MD/NP/PA 	     	Signature		
Comfort Care/DNR Order Verification					
Attention Physician/NP/PA	Pat. Name	     	Gender         M     F	
If used, enter information or print legibly. Physician/NP/ PA must sign, tear off strip, fold, trim, and insert in bracelet.
Massachusetts	Pat. DOB:	     	Expir. Date:	     	Tel.	   -   -    	
	MD/NP/PA 	     	Signature		
Comfort Care/DNR Order Verification					
Attention Physician/NP/PA	Pat. Name	     	Gender         M     F	
If used, enter information or print legibly. Physician/NP/ PA must sign, tear off strip, fold, trim, and insert in bracelet.
Massachusetts	Pat. DOB:	     	Expir. Date:	     	Tel.	   -   -    	
	MD/NP/PA 	     	Signature		
Comfort Care/DNR Order Verification