ORDER FORM
Do Not Resuscitate (DNR)
Medical Orders for Scope of Treatment (MOST)
The Medical Orders for Scope Of Treatment (MOST) form and
the Do Not Resuscitate (DNR) form
May only be ordered by a Physician’s Office or Licensed Health Care Facility
To place an order,
complete this form and mail with a check or money order to:
PAYMENT IN ADVANCE WITH ORDER IS REQUIRED
The cost for either form is 4 cents each
Ship To:
Name:
Organization:
Business Shipping Address:
City: State: Zip:
Telephone:
Description: Quantity:
MOST FORM (pink form)
DNR FORM (yellow form)
Amount for Forms (Total number of Forms X $0.04 each):
Shipping Cost:
AMOUNT DUE:
Check enclosed in amount of:
1 to 10 forms $0.80
11 to 25 forms $1.26
26 to 50 forms $2.18
51 to 100 forms $3.95
101 to 250 forms $5.22
Note: for orders larger than 250,
extrapolate the rate (e.g. for an
order of 1000 forms shipping
cost would be $5.22 X 4, or $20.88)
Shipping costs:
TOTAL number of Forms Ordered:
Cost:
North Carolina Office of Emergency Medical Services
Division of Health Service Regulation
ATTENTION: DNR/MOST Order
2707 Mail Service Center
Raleigh, NC 27699-2707
DNR ORDERFORM DHHS/DHSR/EMS 4900
Please Type or Print Clearly and Use black or blue ink Only:
Date:
Make check or money order payable to:
N.C. Division of Health Service Regulation
