Acknowledgement For Advance Directives - Florida Page 2
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3Suggested form of a Living Will, Florida Statues Section 765.303
A living will may, BUT NEED NOT, be in the following form:
Living Will
Declaration made this ________ day of _______ 2 _______, I ____________________________
willfully and voluntarily make known my desire that my dying not be artificially prolonged un-
der the circumstances set forth below, and I do hereby declare that, if any time I am incapac-
itated and
________ (initial) I have a terminal condition.
or ________ (initial) I have an end stage condition.
or ________ (initial) I am in a persistent vegetative state,
and if my attending or treating physician and another consulting physician have determined
that there is no reasonable medical probability of my recovery from such condition, I direct
that life-prolonging procedures be withheld or withdrawn when the application of such proce-
dures would serve only to prolong artificially the process of dying, 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.
It is my intention that this declaration be honored by my family and physician as the final ex-
pression of my legal right to refuse medical or surgical treatment and to accept the conse-
quences of such refusal.
In the event that I have been determined to be unable to provide express and informed con-
sent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I
wish to designate, as my surrogate to carry out the provisions of this declaration:
Name _______________________________________________________________
Address ______________________________________________________________
City
__________________________________ State _______ Zip __________
Phone
______________________________________________________________
I understand the full import of this declaration, and I am emotionally and mentally competent
to make this declaration.
Additional Instructions (optional):
(Signed): _______________________________
Witness ________________________________ Witness _____________________________
Street Address __________________________ Street Address _______________________
City, State & Zip ________________________ City, State & Zip ______________________
Phone _________________________________ Phone _______________________________
The principal’s failure to designate a surrogate shall not invalidate the living will.
-- This form is offered as a courtesy of the Florida Bar and the Florida Medical Association. –
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