About the Patient
Date of Birth
Hair and Eye Color(s)
The Patient's Preferences
Instruction concerning the administration of CPR
Tissue donation information (optional)
About the Signing Doctor
Full Name and Address
Colorado Medical License Number
If the Patient is in Hospice
Name of the hospice program/provider
The form needs to be completed by both the patient and their doctor.
The form need to be signed by the doctor to be valid.
Discuss your preference with your agent, alternates, doctor, religious leader, or any other person in your life that is part of your support circle.
Wear a pendant or necklace indicating you have a CPR directive (optional).
Who to Notify
To ensure that your wishes are followed and the CPR Directive is acknowledged, make sure you give copies to the following individuals.
Give Copies of Form to:
Agent (if appointed by MDPOA)
Alternate agents, if any