Printing the Nevada POLST Form

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 on 65# stock. Nevada POLST forms may be ordered here. Because forms are printed in large quantities there is only a 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 cardstock
Both sides of the form must be printed back to back and not on separate pages.

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 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 State of Nevada Division of Public and Behavioral Health). They may be picked up or charged to a FedEx account. Click here to order POLST forms.