Don't Amputate My Penis (DAMP) Order

After reading a recent headline about a man who had his penis surgically removed with direct consent, a facebook friend sent out a request that no one allow a surgeon to amputate his penis without his consent.  In order to help his cause, I have created the form below (modeled after the Kentucky Do Not Resuscitate Order).  I'm calling it the Kentucky "Don't Amputate My Penis" (DAMP) Order.

Kentucky Emergency Medical Services

Don’t Amputate My Penis (DAMP) Order

Person's Full Legal Name _______________________________________________________________

Surrogate's Full Legal Name (if applicable) _________________________________________________

I, the undersigned person or surrogate who has been designated to make health care decisions in accordance with Kentucky Revised Statutes, hereby direct that in the event of my unconsciousness that this DON’T AMPUTATE MY PENIS (DAMP) ORDER be honored. I understand that DAMP means that if my penis appears to have morphed into cancerous cauliflower, no medical procedure to remove my vegetable penis will be started by surgical personnel. 

I understand this decision will not prevent medical personnel from providing other medical care that does not involve the removal of my penis.

I understand that I may revoke this DAMP order at any time by destroying this form, removing the DAMP

bracelet, or by telling the surgical personnel that I want my penis to be amputated.

Any attempt to alter or change the content, names, or signatures on the DAMP form shall make the DAMP form invalid.

I understand that this form, or a standard DAMP bracelet must be available and must be shown to surgical personnel immediately. If the form or bracelet is not provided, the surgical personnel will follow their normal penis-amputating protocols.

I understand that should I die, surgical personnel will require this form and/or bracelet for their records.

I give permission for information about this DAMP Order to be given to the pre-hospital emergency

medical care personnel, physicians, nurses, or other health care personnel as necessary to implement this directive.

I hereby state that this Don’t Amputate My Penis (DAMP) Order is my authentic wish not be amputated.

_______________________________________

Person/Legal Surrogate Signature

________________________________

Date

Commonwealth of Kentucky County of ________________________

Subscribed and sworn to before me by ________________________________ to be his/her own free act and deed, this _________ day of ___________________________, 20_________.

___________________________________, Notary Public

My commission expires: __________________________

In lieu of having this Form notarized, it may be witnessed by two persons not related to the

individual noted above.

WITNESSED BY:

1. __________________________________________________

2. __________________________________________________