{"data":{"id":"us-ok/okla.-stat.-tit.-63-63-3131.5","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 63, § 63-3131.5","heading":"Consent form","body":"A. For persons under the care of a health care agency, a do-\n\nnot-resuscitate order shall, if issued, be in accordance with the\n\npolicies and procedures of the health care agency as long as not in\n\nconflict with the provisions of the Oklahoma Do-Not-Resuscitate Act.\n\nB. The do-not-resuscitate consent form shall be in\n\nsubstantially the following form:\n\nFRONT PAGE\n\nOKLAHOMA DO-NOT-RESUSCITATE (DNR) CONSENT FORM\n\nI, _________________________, request limited health care as\n\ndescribed in this document. If my heart stops beating or if I stop\n\nbreathing, no medical procedure to restore breathing or heart\n\nfunction will be instituted by any health care provider including,\n\nbut not limited to, emergency medical services (EMS) personnel.\n\nI understand that this decision will not prevent me from\n\nreceiving other health care such as the Heimlich maneuver or oxygen\n\nand other comfort care measures.\n\nI understand that I may revoke this consent at any time in one\n\nof the following ways:\n\n1. If I am under the care of a health care agency, by making an\n\noral, written, or other act of communication to a physician or other\n\nhealth care provider of a health care agency;\n\n2. If I am not under the care of a health care agency, by\n\ndestroying my do-not-resuscitate form, removing all do-not-\n\nresuscitate identification from my person, and notifying my\n\nattending physician of the revocation;\n\n3. If I am incapacitated and under the care of a health care\n\nagency, my representative may revoke the do-not-resuscitate consent\n\nby written notification to a physician or other health care provider\n\nof the health care agency or by oral notification to my attending\n\nphysician; or\n\n4. If I am incapacitated and not under the care of a health\n\ncare agency, my representative may revoke the do-not-resuscitate\n\nconsent by destroying the do-not-resuscitate form, removing all do-\n\nnot-resuscitate identification from my person, and notifying my\n\nattending physician of the revocation.\n\nI give permission for this information to be given to EMS\n\npersonnel, doctors, nurses, and other health care providers. I\n\nhereby state that I am making an informed decision and agree to a\n\ndo-not-resuscitate order.\n\n____________________ OR ________________________________\n\nSignature of Person Signature of Representative\n\n(Limited to an attorney-in-fact for\n\nhealth care decisions acting under the\n\nOklahoma Health Care Agent Act, a\n\nhealth care proxy acting under the\n\nOklahoma Advance Directive Act or a\n\nguardian of the person appointed under\n\nthe Oklahoma Guardianship and\n\nConservatorship Act.)\n\nThis DNR consent form was signed in my\n\npresence.\n\n______________ ______________________ _____________\n\nDate Signature of Witness Address\n\n______________________ _____________\n\nSignature of Witness Address\n\nBACK OF PAGE\n\nCERTIFICATION OF PHYSICIAN\n\n(This form is to be used by an attending physician only to\n\ncertify that an incapacitated person without a representative would\n\nnot have consented to the administration of cardiopulmonary\n\nresuscitation in the event of cardiac or respiratory arrest. An\n\nattending physician of an incapacitated person without a\n\nrepresentative must know by clear and convincing evidence that the\n\nincapacitated person, when competent, decided on the basis of\n\ninformation sufficient to constitute informed consent that such\n\nperson would not have consented to the administration of\n\ncardiopulmonary resuscitation in the event of cardiac or respiratory\n\narrest. Clear and convincing evidence for this purpose shall\n\ninclude oral, written, or other acts of communication between the\n\npatient, when competent, and family members, health care providers,\n\nor others close to the patient with knowledge of the patient's\n\ndesires.)\n\nI hereby certify, based on clear and convincing evidence\n\npresented to me, that I believe that ___________________________\ninclude oral, written, or other acts of communication between the\n\npatient, when competent, and family members, health care providers,\n\nor others close to the patient with knowledge of the patient's\n\ndesires.)\n\nI hereby certify, based on clear and convincing evidence\n\npresented to me, that I believe that ___________________________\n\nName of Incapacitated Person\n\nwould not have consented to the administration of cardiopulmonary\n\nresuscitation in the event of cardiac or respiratory arrest.\n\nTherefore, in the event of cardiac or respiratory arrest, no chest\n\ncompressions, artificial ventilation, intubations, defibrillation,\n\nor emergency cardiac medications are to be initiated.\n\n__________________________ _____________________________\n\nPhysician's Signature/Date Physician's Name (PRINT)\n\n________________________________________________________________\n\nPhysician's Address/Phone\n\nC. Witnesses must be individuals who are eighteen (18) years of\n\nage or older who are not legatees, devisees or heirs at law.\n\nD. It is the intention of the Legislature that the preferred,\n\nbut not required, do-not-resuscitate form in Oklahoma shall be the\n\nform set out in subsection B of this section.","path":["OK Code","Title 63"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os63.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"2112ed695dc9ce9dbc850e3a5542321223b10e80e92f099284b6c3a363e2a74c","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-63-63-3131.4","next":"us-ok/okla.-stat.-tit.-63-63-3131.6"},"notice":"GroundRules: Original legal text. Not legal advice."}