Living Will PDF

- Email*
  
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- Who is the Declarant, the person for whom this living will is being created?
- Declarant's Name:
- The Declarant is a woman or a man.
- Declarant's Gender:
- What is the address of the Declarant?
- Enter Address:
- Enter City:
- Enter County:
- Select State:
- Enter Zip Code:
- What is the contact information for the Declarant?
- Enter Telephone Number:
- Who do you choose as your Advocate to decide on your behalf when it comes to your health care?
- Enter Advocate's Name:
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- What are the Advocate's mail and phone number?
- Enter Address:
- Enter City:
- Select State:
- Enter Zip Code:
- Enter Telephone Number:
- If the primary advocate is unavailable or unwilling to make healthcare choices on your behalf, would you wish to select an Alternate Advocate?
- Appoint Alternate Advocate:
  - Yes
  - No
- What are the Alternate Advocate's name and contact information?
- Enter Alternate Advocate's Name:
- Enter Address:
- Enter City:
- Select State:
- Enter Zip Code:
- Enter Telephone Number:
- Would you like to appoint a second Alternate Advocate?
- Appoint Second Alternate Advocate:
  - Yes
  - No
- Who is the second Alternate Advocate, and what is their information?
- Enter Second Alternate Advocate Name:
- Enter Address:
- Enter City:
- Select State:
- Enter Zip Code:
- Enter Telephone Number:
- Would you prefer to give the Advocate the ability to make choices about your health care as of a certain date or under a certain circumstance?
- The Advocate's authority to make health care decisions for you will commence if your physician determines you lack the capacity to make your own decisions or you become incapacitated. Would you like to specify another circumstance?:
  - Yes
  - No
- Specify Date or State Condition:
- Commencement Date:
  DD slash MM slash YYYY
- Enter Details:
- Will this living have a health care power of attorney linked to it?
- Attach Health Care Power of Attorney:
  - Yes
  - No
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- If you are diagnosed with a terminal illness, would you like to specify in this living will whether you want to receive life-sustaining medical care?
- Specify care in case of terminal illness:
  - Yes
  - No
- Do you wish to receive or not receive life-sustaining medical treatment if diagnosed with a terminal illness?:
- If you enter a permanent unconscious or vegetative condition, would you like to specify in this living will whether you want to accept or reject life-sustaining medical care?
- Specify vegetative care:
  - Yes
  - No
- Do you wish to receive or not receive life-sustaining medical treatment if you fall into a permanent unconcious or vegetative state?:
- Would you like to specify in this living will whether you want to accept or reject medical treatment that would keep you alive if you become somewhat unconscious but still unable to make decisions?
- Specify marginally conscious care:
  - Yes
  - No
- Do you wish to receive or not receive life-sustaining medical treatment if you go into a marginally unconcious state?:
- Would you like to specify in this Living Will whether you want to accept or reject medical care that would keep you alive if you were to be diagnosed with an incurable illness or experience excruciating pain?
- Specify care for untreatable condition:
  - Yes
  - No
- Do you wish receive or not receive life-sustaining medical care if you are diagnosed with an untreatable condition or are in severe pain?:
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- Do you want CPR performed on you to extend your life?
- Select Option:
- Do you want to try to extend your life by using a respirator or ventilator, or do you want to avoid doing so?
- Select Option:
- Do you want to be fed through a tube to extend your life
- Select Option:
- Do you want to or do you not want to get blood transfusions to extend your life?
- Select Option:
- Do you want to undergo invasive diagnostic procedures such as surgery or surgery to extend your life?
- Select Option:
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- Do you want to try to extend your life by getting renal dialysis or not?
- Select Option:
- Do you want to be given antibiotics or other treatments to extend your life?
- Select Option:
- Do you want to take painkillers with the highest potency or not?
- Select Option:
- Do you want to be given the strongest painkillers possible, even if they could speed up your death?
- Select Option:
- Do you want to take or not take the strongest painkillers possible, even if they can lead to a brief addiction if you get well or survive your condition?
- Select Option:
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- Do you want to add any more details on comfort care or life-sustaining treatment?
- Additional Instructions?:
  - Yes
  - No
- What additional directives would you like to include?:
- Please check the boxes next to any circumstances in which you wouldn't want to extend your life.
- Do not prolong life if:
  - I have an incurable or irreversible condition
  - I become permanently unconscious or fall into a vegetative state
  - Third Choice
- If you didn't select any of the above options, would you like to state in your Living Will that you wish to prolong life to the greatest extent possible within accepted health care standards?:
  - Yes
  - No
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- Do you want to choose a primary healthcare provider?
- Appoint Primary Physician?:
  - Yes
  - No
- What are the name, phone number, and address of the primary care physician?
- Enter Physician's Name:
- Enter Address:
- Enter City:
- Select State:
- Enter Zip Code:
- Enter Telephone Number:
- Would you like to include a different medical professional?
- Alternate Physician:
  - Yes
  - No
- What is the name, address, and phone number of the replacement physician?
- Enter Alternate Physician's Name:
- Enter Address:
- Enter City:
- Select State:
- Enter Zip Code:
- Enter Telephone Number:
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- Who will serve as the first witness at the signing of this living will?
- Enter Name:
- Enter Address:
- Enter City:
- Select State:
- Enter Zip Code:
- Enter Telephone Number:
- Who will serve as the second witness at the signing of this living will?
- Enter Name:
- Enter Address:
- Enter City:
- Select State:
- Enter Zip Code:
- Enter Telephone Number:
- Which state and which county will this living will be signed and/or filed in?
- Select State:
- Enter County Name:
- What state's laws will apply to this contract?
- Select State:
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Living Will

Living Will

Step 1 of 11

Who is the Declarant, the person for whom this living will is being created?

The Declarant is a woman or a man.

What is the address of the Declarant?

What is the contact information for the Declarant?

Who do you choose as your Advocate to decide on your behalf when it comes to your health care?

What are the Advocate's mail and phone number?

If the primary advocate is unavailable or unwilling to make healthcare choices on your behalf, would you wish to select an Alternate Advocate?

What are the Alternate Advocate's name and contact information?

Would you like to appoint a second Alternate Advocate?

Who is the second Alternate Advocate, and what is their information?

Would you prefer to give the Advocate the ability to make choices about your health care as of a certain date or under a certain circumstance?

Will this living have a health care power of attorney linked to it?

If you are diagnosed with a terminal illness, would you like to specify in this living will whether you want to receive life-sustaining medical care?

If you enter a permanent unconscious or vegetative condition, would you like to specify in this living will whether you want to accept or reject life-sustaining medical care?

Would you like to specify in this living will whether you want to accept or reject medical treatment that would keep you alive if you become somewhat unconscious but still unable to make decisions?

Would you like to specify in this Living Will whether you want to accept or reject medical care that would keep you alive if you were to be diagnosed with an incurable illness or experience excruciating pain?

Do you want CPR performed on you to extend your life?

Do you want to try to extend your life by using a respirator or ventilator, or do you want to avoid doing so?

Do you want to be fed through a tube to extend your life

Do you want to or do you not want to get blood transfusions to extend your life?

Do you want to undergo invasive diagnostic procedures such as surgery or surgery to extend your life?

Do you want to try to extend your life by getting renal dialysis or not?

Do you want to be given antibiotics or other treatments to extend your life?

Do you want to take painkillers with the highest potency or not?

Do you want to be given the strongest painkillers possible, even if they could speed up your death?

Do you want to take or not take the strongest painkillers possible, even if they can lead to a brief addiction if you get well or survive your condition?

Do you want to add any more details on comfort care or life-sustaining treatment?

Please check the boxes next to any circumstances in which you wouldn't want to extend your life.

If you require a Guardian, would you like to designate the person who would be in charge of taking care of your daily needs?

Would you prefer to name the Advocate in charge of making choices about your medical treatment as your Guardian?

Would you like to appoint someone else to act as your Guardian?

What is name, address and telephone number of the person you would like to appoint as your Guardian?

Would you like to include an alternate Guardian?

What is the name, address and telephone number of the the alternate Guardian?

Would you like to include a second alternate guardian?

What is the name, address and telephone number of the second alternate Guardian?

Would you desire to donate any organs once you pass away?

Please specify specify which organs and/or tissues you would like to donate upon death?

Do you consent to have your donated body, organs, and body parts used for any legal justification?

Do you wish to allow your donated body or donated organs and tissues to be used for transplantation?

Do you wish to allow your donated body or donated organs and tissues to be used for therapy (e.g., gene therapy)?

Do you wish to allow your donated body or donated organs and tissues to be used for study or research?

Do you wish to allow your donated body or donated organs and tissues to be used for medical education?

Do you want to choose a primary healthcare provider?

What are the name, phone number, and address of the primary care physician?

Would you like to include a different medical professional?

What is the name, address, and phone number of the replacement physician?

Who will serve as the first witness at the signing of this living will?

Who will serve as the second witness at the signing of this living will?

Which state and which county will this living will be signed and/or filed in?

What state's laws will apply to this contract?