Do Not Resuscitate (DNR) & POLST California

Document Name
Emergency Medical Services Pre-Hospital Do Not Resuscitate (DNR) form
Physician Orders for Life Sustaining Treatment (POLST) form
Where do you get the forms
You should get the DNR or POLST form from a medical professional or download it here:
Who is permitted to request a DNR or a POLST

A patient with a life threatening illness or injury can request a DNR or a POLST.

Who signs the form
The form is signed by the physician as well as the patient.
Patient Identification
There is no requirement for a patient to wear a DNR identification medallion.  However, California does recognize the medallion as proof of the patient having a DNR order.
How do you obtain a DNR medallion
There are currently only two state approved providers who can produce the pre-hospital DNR medallions.  They are:
Medic Alert Foundation 888-633-4298
Caring Advocates 800-647-3223
You will have to submit a copy of the DNR prior to being allowed to purchase a medallion.
Revoking a DNR or a POLST
An order can be revoked at any time.  Just destroy the paperwork and also notify your doctor’s office and family.
Photocopies of a completed DNR or POLST form are valid.
State info link


Other links
Special Notes
Order a Vial of Life decal for your front door. The decal informs Emergency Medical Services team a DNR has been prepared and can be found in your refrigerator.