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Get MN Provider Orders For Life-Sustaining Treatment (POLST) 2017-2024

Rders are based on the patient s current medical condition and preferences. Any section not completed does not invalidate the form and implies full treatment for that section. With significant change of condition new orders may need to be written. Patients should always be treated with dignity and respect. A CHECK ONE LAST NAME FIRST NAME MIDDLE INITIAL DATE OF BIRTH PRIMARY MEDICAL CARE PROVIDER NAME CARDIOPULMONARY RESUSCITATION (CPR) PRIMARY MEDICAL CARE PROVIDER PHONE (WITH ARE.

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