Fillable Supplemental Estate Planning Intake Form Single Person (Page 3 of 4) in pdf

Supplemental Estate Planning Intake Form Single Person Page 3

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Terminal Condition (ORC 2133.01) - means an irreversible, incurable, and

untreatable condition caused by disease, illness, or injury from which, to a reasonable

degree of medical certainty as determined in accordance with reasonable medical

standards by a declarant’s or other patient’s attending physician and one other

physician who has examined the declarant or other patient, both of the following

apply:

(1) There can be no recovery.

(2) Death is likely to occur within a relatively short time if life-sustaining

treatment is not administered.

Permanently Unconscious State (ORC 2133.01) - means a state of permanent

unconsciousness in a declarant or other patient that, to a reasonable degree of

medical certainty as determined in accordance with reasonable medical standards by

the declarant’s or other patient’s attending physician and one other physician who

has examined the declarant or other patient, is characterized by both of the

following:

(1) Irreversible unawareness of one’s being and environment.

(2) Total loss of cerebral cortical functioning, resulting in the declarant or

other patient having no capacity to experience pain or suffering.

2. Do you intend for this declaration to authorize your attending physician to withhold

or withdraw life-sustaining treatment when you are in a permanently unconscious

state and when the nutrition and hydration will not or no longer serve to provide

comfort to you or alleviate your pain?

Yes

3. Do you intend to make an anatomical gift upon your death?

Yes

Anatomical Gift (ORC 2108.01) - means a donation of all or part of a human body

to take effect after the donor’s death for the purpose of transplantation, therapy,

research, or education.

If yes, select an option:

Option 1:

Upon my death, I make an anatomical gift of my organs, tissues, and

eyes for any purpose authorized by law.

Supplemental Estate Planning Intake Form – Single Person – Version 14.1

Page 3 of 4

Supplemental Estate Planning Intake Form Single Person Page 3

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