top of page

Printing the Nevada POLST Form


Nevada POLST forms may be ordered here


Printing the Spanish version of Nevada POLST 

The Spanish version is ONLY for reference. Please note that it does not include signature space for the provider, patient or their representative or surrogate. This is because the Spanish version is just a translation for a Spanish-speaking patient to follow. Because we must assume that providers may not read Spanish and must be able to follow the orders of a Nevada POLST, the actual medical order must be completed on the pink English version. Feel free to print this Spanish version for your Spanish speaking patients and their families in order to understand the form being completed.


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 for educational and public dissemination.


A POLST Form requires a signature of a physician, APRN or PA, and the patient or their representative or surrogate to be valid and should only be filled out and signed after an in-depth conversation between the patient and healthcare 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 to find out about POLST Programs and forms in your state.

Printed, regulation-conforming POLST forms are available from this site. The forms are free (thank you to the State of Nevada Division of Public and Behavioral Health). They may be picked up or charged to a FedEx accountClick here to order POLST forms.

bottom of page