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.

  • POLST printing guidelines
    • Copy or print forms should be on 65# bright pink cardstock.
    • The form must not be altered in any way including the overall layout, text, or images.
    • Form sides must be printed back-to-back, not on separate pages.

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 printed and given for educational and informational purposes only.

To be valid, a POLST Form requires the signature of a physician, APRN or PA, and the patient or their representative or surrogate. It 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 to find out about POLST Programs and forms in other states.

Printed POLST forms that comply with state regulations can be ordered at no cost (except for shipping, if desired). Click here to order Nevada POLST forms from the state Department of Health and Human Services.

    Printing Spanish version of Nevada POLST

    The Spanish version is only for reference. 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 responders and/or providers who need to understand and follow the completed POLST may not read Spanish, the actual medical order must be completed on the pink English version. Feel free to print the Spanish version linked below for your Spanish-speaking patients and their families so they can understand the form being completed.