Living Will
This Living Will is a document that expresses your healthcare wishes in the event that you are unable to communicate them yourself. It is important to ensure that your desires regarding medical treatment are clearly outlined, in accordance with your state's laws.
Please note that laws regarding Living Wills can differ from state to state. Ensure that you are complying with the laws specific to your state.
Personal Information:
- Full Name: ____________________________________________
- Address: ____________________________________________
- City, State, Zip Code: ______________________________
- Date of Birth: _______________________________________
Healthcare Preferences:
I, the undersigned, wish to provide guidance concerning my healthcare preferences in the event that I am unable to communicate my wishes. My preferences are as follows:
- If I have a terminal condition, I do not wish to receive life-sustaining treatment if it only prolongs the dying process.
- If I am in a persistent vegetative state or a condition with no hope of recovery, I would like to refuse any life-sustaining treatment.
- If I require pain relief, I wish to receive such treatment, even if it may hasten death.
Appointment of Healthcare Proxy:
I hereby designate the following individual as my healthcare proxy, to make healthcare decisions on my behalf if I am unable to do so:
- Full Name: ____________________________________________
- Relationship: ______________________________________
- Contact Information: _______________________________
Witnesses:
This document must be signed in the presence of two witnesses who are at least 18 years of age and are not named as healthcare proxies. The witnesses must sign below:
- Witness 1 Name: ______________________________________
- Witness 1 Signature: ________________________________
- Witness 2 Name: ______________________________________
- Witness 2 Signature: ________________________________
Signature:
By signing this Living Will, I affirm that I understand its contents and have voluntarily executed this document.
Signature: ____________________________________________
Date: _______________________________________________