Florida Living Will Declaration Template And Health Care Surrogate printable pdf download

FLORIDA LIVING WILL DECLARATION

AND HEALTH CARE SURROGATE

On this ___ day of _________, 20__, I, (Print Name)

of: (Mailing Address)

(City and State)___________________________________ (Zip Code)

Phone: (_____)

Date of Birth:

E-Mail Address:

Willfully and voluntarily make known my desire that my dying not be artificially

prolonged under the circumstances set forth below, and I do hereby declare that, if at any

time I am mentally or physically incapacitated and:

_____ (Initial) I have a terminal condition, or

_____ (Initial) I have an end-stage condition, or

_____ (Initial) I am in a persistent vegetative state

_____ (Initial) I do not want to be tube fed

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condition, I direct that life-prolonging procedures be withheld or withdrawn when the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 procedures 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 physicians as the final expression of my legal right to refuse medical or

surgical treatment and to accept the consequences for such refusal. In the event that I

have been determined to be unable to provide expressed and informed consent 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___________________________________Phone (____)

Address________________________________________Zip

Alternate: Name___________________________ Phone (____)

Address________________________________________________Zip

America Living Will Registry, LLC, 2814 Beach Boulevard South, St. Petersburg, FL 33707

1-866-305-ALWR

web site:

e-mail:

Florida Living Will Declaration Template And Health Care Surrogate