Fillable Virginia Advance Directive Form (Page 3 of 3) in pdf

3. I provide the following other instructions concerning my health care:

[YOU MAY WRITE HERE STATEMENTS AND INSTRUCTIONS ABOUT TREATMENTS THAT YOU DO WANT, IF MEDICALLY APPROPRIATE, OR ABOUT TREATMENTS YOU

DO NOT WANT UNDER SPECIFIC CIRCUMSTANCES OR ANY CIRCUMSTANCES. IT IS IMPORTANT YOUR INSTRUCTIONS HERE DO NOT CONFLICT WITH OTHER

INSTRUCTIONS YOU HAVE GIVEN IN THIS ADVANCE DIRECTIVE.]

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SECTION III: ANATOMICAL GIFTS

(YOU MAY USE THIS DOCUMENT TO RECORD YOUR DECISION TO DONATE YOUR ORGANS, EYES AND TISSUES OR YOUR WHOLE BODY AFTER YOUR DEATH.

IF YOU DO NOT MAKE THIS DECISION HERE OR IN ANY OTHER DOCUMENT, YOUR AGENT CAN MAKE THE DECISION FOR YOU UNLESS YOU SPECIFICALLY

PROHIBIT HIM/HER FROM DOING SO, WHICH YOU MAY DO IN THIS OR SOME OTHER DOCUMENT. CHECK ONE OF THE BOXES BELOW IF YOU WISH TO USE

THIS SECTION TO MAKE YOUR DONATION DECISION.)

p I donate my organs, eyes and tissues for use in transplantation, therapy, research and education. I direct that all necessary measures be

taken to ensure the medical suitability of my organs, eyes or tissues for donation. I understand that I may register my directions at the

Department of Motor Vehicles or directly on the donor registry, , and that I may use the donor registry to

amend or revoke my directions; OR

p I donate my whole body for research and education.

[Write here any specific instructions you wish to give about anatomical gifts.]

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AFFIRMATION AND RIGHT TO REVOKE

: By signing below, I indicate that I understand this document and that I am

willingly and voluntarily executing it. I also understand that I may revoke all or any part of it at any time as provided by law.

Date

Signature of Declarant

The declarant signed the foregoing advance directive in my presence.

[TWO ADULT WITNESSES NEEDED]

_________________________________________________________

Witness Signature

Witness Printed

_________________________________________________________

Witness Signature

Witness Printed

This form satisfies the requirements of Virginia's Health Care Decisions Act. If you have legal questions about this form or would like to develop a

different form to meet your particular needs, you should talk with an attorney. It is your responsibility to provide a copy of your advance directive to

your treating physician. You also should provide copies to your agent, close relatives and/or friends. For information on storing this advance directive

in the free Virginia Advance Health Directive Registry, go to This form is provided by the Virginia Hospital &

Healthcare Association as a service to its members and the public. (June 2012, ) seg

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