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Metal Bracelet DNR Order Form - eforms

Metal Bracelet DNR Order Form - eforms 2025

Metal Bracelet DNR Order Form - eforms Preview on Page 1

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The document is a purchase form for metal Do Not Resuscitate (DNR) bracelets issued by the Connecticut College of Emergency Physicians. It outlines the ordering process, required documentation, payment methods, and engraving details for the bracelets. The form specifies that orders must be placed by designated agencies or physicians, includes costs, and emphasizes confidentiality of patient information.

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Click ‘Get Form’ to open the Metal Bracelet DNR Order Form in the editor.
Begin by entering the 'Ordering Institution/Licensed Physician' and 'Contact Person' details, including their name, mailing address, and phone number.
Ensure you have a completed Do Not Resuscitate Verification Order ready for upload. This must be signed by a licensed CT Physician.
Upload a copy of the patient’s valid driver’s license, social security card, or birth certificate as required for identification.
Fill in the engraving information: provide the full legal name for front engraving (maximum 20 letters) and the physician's name and phone number for reverse engraving.
Select whether you need an Adult or Pediatric Bracelet by checking the appropriate box.
Review all entered information for accuracy before submitting your order along with payment via business check or money order.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What should my medical alert bracelet say?

We find that the best health information to include on medical ID jewelry is: First and Last Name. Medical Conditions. Allergies.

What information should be on a DNR bracelet?

How a Patient Obtains a DNR Bracelet: A patient, or the patients authorized representative, can obtain a DNR bracelet only by requesting one from the patients personal physician, or the attending physician at the health care facility where the patient resides.

Is a DNR medical bracelet legally binding?

It serves as an important alert to healthcare providers but isnt always legally binding on its own. In most regions, a DNR bracelet must be tied to a valid DNR order, signed by a licensed physician, to be honored. The primary role of a DNR bracelet is to act as a quick reference for medical personnel.

What to engrave on a medical alert bracelet?

When it comes to engraving your medical alert bracelet, there are a lot of options, but we recommend: Your full name: If theres room after your name, consider using the rest of the line. Your chief medical condition(s) or concern(s): Your allergies or medications: Your emergency contact information:

Which information should be included in the DNR?

In California, a DNR order must include the patients name and the date of the order, and must be signed by you (or your healthcare agent) and your physician.