Vermont Statutory Form With Will To Live Language printable pdf download

Vermont Statutory Form With Will To Live Language

Vermont Statutory Form

with Will to Live Language

ADVANCE DIRECTIVE

I, (your name)__________________________________________________________________

(your address)__________________________________________________________________

_____________________________________________________________________________

(your phone number)____________________________________________________________

hereby appoint:

(Name of agent)________________________________________________________________

(address of agent)_______________________________________________________________

(phone number(s) of agent)_______________________________________________________

as my agent to make any and all health care decisions for me, except to the extent I state

otherwise in this document.

In the event the person I appoint above is unable, unwilling, or unavailable to act as my health

care agent, I hereby appoint:

(successor agent’s name)_________________________________________________________

(successor agent’s address)________________________________________________________

_____________________________________________________________________________

(successor agent’s phone number)__________________________________________________

as alternate agent . This Advance Directive shall take effect in the event I become unable to

make my own health care decisions.

If any court determines that it is necessary to appoint someone to serve as guardian of my

personal affairs, including the responsibility for making decisions regarding my support, care,

health, safety, rehabilitation, education, therapeutic treatment, and residence, I request the court

give primary consideration to the person serving as my agent hereunder.

(a)

STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS

REGARDING HEALTH CARE DECISIONS.

Here you may include any specific desires or limitations you deem appropriate such as

when or what life-sustaining measures should be withheld; directions whether to continue or

discontinue artificial nutrition and hydration; or instructions to refuse any specific types of

Vermont Statutory Form With Will To Live Language