POLST Form Printing Instructions

Health care providers may print Nevada POLST forms for use with their patients, but are discouraged from doing so. For easy recognition by EMS, forms should be bright pink and printed double-sided. Nevada POLST forms may be ordered here. Because we print in large quantities and only charge for shipping and a very nominal handling fee, it is likely less expensive for providers to order POLST forms rather than print them in-house.

Printing requirements
If printing in-house, be aware the Nevada POLST form is a State regulated protected document and, in order to print the form, certain guidelines must be followed:

  • The form must not be altered in any way including the overall layout, text, or images
  • Copy or print forms should be on 65# bright pink card stock
  • Both sides of the form must be printed back to back and not on separate pages.

Printing Template for the Physician Information of Section C
If the same physician information (printed name, address, phone and license number) will always be entered in section C of the Nevada POLST form, you may use this MS Word Template to print that information on the Nevada POLST forms so it need not be entered each time. The physician’s signature and date will always need to be entered each time. None of the red text will print. Simply replace the “ENTER [] HERE” text with the appropriate information, print a test page on plain paper to determine direction of print, then load POLST forms into your printer, in your printer dialog box enter the number of copies and print.

Printing a SAMPLE POLST form: Because the POLST form is a medical order it should not be given to the public. Instead, a sample POLST should be given for other than patient care. Please print this SAMPLE POLST form for educational and public dissemination.

A POLST Form requires a signature of a physician and the patient or their representative 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 patient’s goals of care.

The Nevada POLST form may be updated periodically. Please check back annually 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 Nevada visit http://www.polst.org to find out about POLST Programs and forms in your state.

Printed, regulation conforming POLST forms are available on this site. The forms are free (thank you to the Auxillary with the Washoe County Medical Society). Only postage and a nominal handling fee is charged. Click here to order POLST forms.