Fillable Advance Medical Directive Form - Virginia State (Page 2 of 2) in pdf

Add below any additional powers you give your agent, limits you impose on your agent or other information to guide your agent:

Section 2. “Living Will”

(Cross through this section if you do not want to make a "living will" in this form.)

If at any time my attending physician should determine that I have a terminal condition where the application of life-prolonging procedures

would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to

die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with

comfort care or to alleviate pain. OPTION: I specifically direct that the following procedures or treatments be provided to me:

In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this declaration

shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the

consequences of such refusal.

Section 3. Appointment of Agent to Make Anatomical Gift

(Cross through this section if you do not want to appoint an agent to make an anatomical gift or organ, tissue or eye donation for you.)

Upon my death, I direct that an anatomical gift of all of my body, or certain organ, tissue or eye donation may be made pursuant to

applicable Virginia law governing anatomical gifts and in accordance with my directions, if any. I hereby appoint as my agent

Same agent named in Section 1 OR

Primary Agent

Telephone Number

Fax Number

Address

E-mail Address

to make any such anatomical gift or organ, tissue or eye donation following my death. I further direct that:

(Declarant’s directions, if any, concerning anatomical gift or organ, tissue or eye donation)

You must complete the following portions of this form:

This advance directive shall not terminate in the event of my disability. By signing below, I indicate that I am emotionally and mentally

competent to make this advance directive and that I understand the purpose and effect of this document.

________________________________________

_______________________________________________________________________________________

Date

Signature of declarant

The declarant signed the foregoing advance directive in my presence.

________________________________________

Witness

This form, with slight variations, is suggested for use by the Virginia General Assembly in the Health Care Decisions Act and satisfies the requirements of

Virginia law. You may complete any or all of the three numbered sections of the form. If you have legal questions about this form, or would like to develop

a different form to meet your particular needs, you are urged to talk with an attorney. It is your responsibility under Virginia law to provide a copy of your

advance medical directive to your attending physician. You also should provide copies to your agent, close relatives and/or friends.

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This form is provided by the Virginia Hospital & Healthcare Association as a service to its members. (July 2005, vhha)