The New Hampshire P-DNR form is a bright pink, portable Do Not Resuscitate order that tells emergency responders not to perform CPR if your heart or breathing stops, and it is valid anywhere in the state. Your attending practitioner writes the order, you both sign it, and you keep the original where responders can see it. Without that visible pink form, a wallet card, or an NH-DNR bracelet or necklace at the scene, crews will perform full resuscitation.
Why the Form Is Portable
A DNR written inside a hospital applies only inside that hospital. The P-DNR exists so a single document follows you between home, care facilities, and transport. Under RSA 137-J:26, portable DNR and POLST forms indicating “Do Not Resuscitate” are transferable, valid medical orders throughout New Hampshire.1New Hampshire General Court. New Hampshire Code 137-J:26 – Issuance of a Do Not Resuscitate Order; Order to Be Written by the Attending Practitioner EMS crews, home health aides, and facility staff across the state recognize the pink form on sight.
Who Can Request One
Any person in New Hampshire can request a P-DNR. The statute does not limit the order to people with a terminal diagnosis or a particular condition. Under RSA 137-J:26, an attending practitioner may issue a DNR order for a person if that person, or their healthcare agent or surrogate, has consented.1New Hampshire General Court. New Hampshire Code 137-J:26 – Issuance of a Do Not Resuscitate Order; Order to Be Written by the Attending Practitioner In practice, providers write these orders for patients with serious or progressive illness, but the legal trigger is informed consent, not a specific diagnosis.
How to Get the Form
You cannot fill the P-DNR out at home and bring it in for a signature. Your physician, physician associate, or APRN initiates and completes it as a medical order during an appointment or care conversation. The form is printed on distinctive bright pink paper so emergency responders spot it immediately.2Foundation for Healthy Communities. Portable Medical Orders The Foundation for Healthy Communities, which coordinates advance care planning resources statewide, also hosts a sample version on its website.
Completing Each Section
The form has two main sections plus a detachable wallet card at the bottom.
Patient Information at the Top
The top of the form captures your identifying details so responders can confirm the order belongs to you: your last name and first name with middle initial, your date of birth in numerical form, and the last four digits of your Social Security number as a secondary identifier.
Section A: Do Not Attempt Resuscitation
Section A is the core of the order. Check the box indicating a DNR, then complete two signature blocks.3Foundation for Healthy Communities. Sample P-DNR Form The attending practitioner prints their name and title (MD, DO, APRN, or PA), signs, and records the date and time. You then print your name, sign, and record the date, time, address, and phone number. If you are a minor or have a durable power of attorney for healthcare (DPOAH) or guardian acting for you, that representative signs in your place. A separate “Form Preparer” line captures the name, signature, and date of anyone who helped prepare the form.
Section B: Advance Directives and Other Wishes
Section B records whether you have other planning documents in place. It asks whether you have a durable power of attorney for healthcare and a will, with space to note where each is kept. An open field at the bottom lets you add other instructions or note special circumstances, such as religious considerations or facility-specific preferences.
The Detachable Wallet Card
The bottom of the pink form is a perforated P-DNR wallet card. Once the form is complete, tear off the card and carry it with you at all times. It includes your name, your provider’s name, signature lines for both of you (plus your healthcare agent, if applicable), and phone numbers for you, your provider, and your agent. The form itself instructs: “Keep it on your person at all times even if you decide to wear a NH-DNR bracelet.”3Foundation for Healthy Communities. Sample P-DNR Form
Adding a DNR Bracelet or Necklace
New Hampshire also recognizes a DNR bracelet or necklace as a valid form of the order. Under RSA 137-J:33, the jewelry must be inscribed with your name, your date of birth in numerical form, and either “NH DNR” or “NH Do Not Resuscitate.”4New Hampshire General Court. New Hampshire Code 137-J:33 – Do Not Resuscitate Identification You can only obtain one after presenting a properly executed P-DNR form, a medical orders form with a documented DNR, or a DNR written under a healthcare facility’s policy. The jewelry supplements the pink form; it does not replace it, and you should still carry the wallet card.
Where to Keep the Pink Form
The original signed pink form needs to sit where emergency personnel will find it without searching. At home, the most common location is the front of the refrigerator, which New Hampshire EMS crews are trained to check. In a care facility, the form goes in your medical chart.2Foundation for Healthy Communities. Portable Medical Orders When you transfer between facilities or get discharged, the original pink form must travel with you. The form prints this reminder in bold: “Send original pink form with patient when transferred or discharged.”3Foundation for Healthy Communities. Sample P-DNR Form A clear plastic sleeve protects the paper while keeping it visible. If responders cannot find the form, wallet card, or DNR jewelry, they will perform full resuscitation.
How a POLST Fits In
New Hampshire uses two portable medical orders that overlap. The P-DNR addresses one question: should CPR be performed? A POLST (Physician Orders for Life-Sustaining Treatment), printed on bright yellow paper and also signed by a physician, PA, or APRN, covers that question plus broader preferences such as ventilators, IV antibiotics, and artificial nutrition.2Foundation for Healthy Communities. Portable Medical Orders If your POLST includes the statement “This will constitute a DNR Order, and no separate DNR Order will be required,” it replaces the pink form for DNR purposes.1New Hampshire General Court. New Hampshire Code 137-J:26 – Issuance of a Do Not Resuscitate Order; Order to Be Written by the Attending Practitioner If it does not include that language, you need a separate P-DNR to ensure responders withhold CPR. Ask your provider which combination fits your situation.
Revoking or Changing the Order
You can cancel a P-DNR at any time, regardless of your medical condition. To revoke it, destroy the pink form and remove any DNR bracelet or necklace, then notify your attending physician or APRN that you want the order revoked.2Foundation for Healthy Communities. Portable Medical Orders Your DPOAH can revoke the order on your behalf using the same process. If a provider is voiding the form rather than the patient destroying it, the correct procedure is to write “VOID” in large letters across the form, then sign, date, and time it.3Foundation for Healthy Communities. Sample P-DNR Form Destroy the wallet card as well. Review the form any time you change your mind, experience a major change in health, or transfer to a new facility. Once the order is revoked and no valid form, wallet card, or DNR jewelry is present, responders will perform CPR under their standard protocol.