Oregon POLST Form - Free Download
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Oregon POLST Form
Oregon POLST Form
Health care providers are authorized to print Oregon POLST Forms for use with their patients. The Oregon
POLST Form remains a copyright protected document and in order to print the form certain guidelines must be
Requirements and information for printing Oregon POLST Forms
The form must not be altered in any way including the overall layout, text, or images.
Copy or print forms on 65# Cover Ultra Pink card stock*
Both side of the form must be printed back to back and not on separate pages
A POLST Form requires a signature from an MD, DO, PA, or NP to be valid and should only be filled
out and signed after an in-depth conversation between the patient and health care provider about the
patients goals of care
The Oregon POLST Form is updated every two to three years. Please check back periodically to make
sure that you are using the most current version of the form
Forms differ from state to state depending on local laws and requirements. If you are a patient or
provider outside of Oregon visit www.polst.org to find out about POLST Programs and Forms in your
Written authorization is still required to reproduce the Oregon POLST Form for purposes other than
patient care. To request authorization email polst@ohsu.edu.
If you have questions about the Oregon POLST Program or Oregon POLST Form visit www.orpolst.org
*Mohawk BriteHue Ultra Pink card stock is available online and at some retailers.
Suggested online vendors for Ultra Pink card stock:
MedPass www.medpass.com
Boyd’s Imaging Products www.iboyds.com
Mohawk Paper Store www.mohawkpaperstore.com
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Oregon POLST Form