Fillable Acknowledgement For Advance Directives - Florida printable pdf download

ACKNOWLEDGEMENT FOR ADVANCE DIRECTIVES

As your Medical Doctor, we need to know if you have executed an Advance Medical Directive:

Yes ________ No ________

If yes, this Directive is in the form of:

________ A Living Will

________ A Do Not Resuscitate Order

________ A Health Care Surrogate

________ An Anatomical Donor Form

If you answered YES, could you please provide us with a copy of the forms at your earliest

convenience, sign below, and proceed to the next page.

If you answered NO, please read the following statement and sign below.

Every competent adult has the right to make decisions concerning his or her own health, in-

cluding the right to choose or refuse medical treatment. When a person becomes unable to

make decisions due to a physical or mental change, such as being in a coma or developing

dementia (like Alzheimer’s disease), they are considered incapacitated. To make sure an inca-

pacitated person’s decisions about their health care will still be respected, Advance Directives

were created. These directives outline in writing your wishes regarding future medical treat-

ment. Without any written instructions from you, your family and physicians would have to

guess what treatment you would want. In some cases, they may be forced to proceed with

treatments they know you would not desire simply because your preference was not ex-

pressed in writing. There are several types of advanced directives:

Living Will: It is a written statement of the kind of medical care you want or do not want if

you become unable to make your own decisions.

Health Care Surrogate: This document names another person as your representative to make

medical decisions for you if you are unable to make them yourself. You can include instruc-

tions about your treatment you want or do not want, similar to a living will.

Anatomical Donor form: It is a document that indicates your wish to donate, at death, all or

part of your body. You can indicate your choice to be an organ donor by designating it on your

driver’s license or state identification card, signing a uniform donor form, or expressing your

wish in a living will.

DNR form: This is a yellow form that identifies people who do not wish to be resuscitated in

the event that they stop breathing or their heart stops beating.

The Advance Directives come into effect only if you become incapacitated and you can

change it at any time. As long as you are capable, you should discuss your expectations for

future medical care with your physician. However, before you fill out the Advance Directives

you may also want to talk to your family, friends, lawyer or spiritual advisor.

________ Check here if you would like to receive advance directive forms from our office.

________________________________

__________________

Patient Signature

Date

________________________________

__________________

Patient Printed Name

DOB

SS#

Acknowledgement For Advance Directives - Florida

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