1. Document: DNR/POLST CLICK HERE TO VIEW.

CLINICIAN: Enter FAX or Email to get copy of signed form:
(Fax # like: 15551234567)

My DNR/POLST Instructions include:

• See/download my DNR or POLST
• No I.V. & No Oral Fluids
• Do Not Hospitalize unless needed for comfort care
• No CPR but DO treat otherwise.

2. If you find me unconscious, consider:

Conditions I have:
• I have diabetes (Type II)

Drugs I am taking:
• I am taking Metformin

Allergies:
• I am allergic to Penicillin