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Download The POLST Form

POLST forms can be ordered in bulk from Med-Pass


Translations of the POLST form are available to assist healthcare providers in explaining the form to patients and loved ones. However, an English version of the POLST form must be completed and signed so that emergency medical personnel and healthcare providers can follow the orders.

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POLST – Physician Orders for Life-Sustaining Treatment

Physician Orders for Life-Sustaining Treatment (POLST) is a form that gives seriously-ill patients more control over their end-of-life care, including medical treatment, extraordinary measures (such as a ventilator or feeding tube) and CPR. Printed on bright pink paper, and signed by both a patient and physician, nurse practitioner or physician assistant, POLST can prevent unwanted or ineffective treatments, reduce patient and family suffering, and ensure that a patient's wishes are honored.
Download the POLST form.

When you purchase your POLST forms through Med-Pass, you are supporting
the Coalition for Compassionate Care of California. Thank you!

The Coalition for Compassionate Care of California has created and compiled a variety of resources to help educate patients, caregivers, and healthcare professionals on the issues – both medical and deeply personal – surrounding POLST.