Advance Directive For Health Care Page 3
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2
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4Q
My entire body
Yes
or
Q
the following body organs or parts:
Yes
G
G
lungs
liver
G
G
pancreas
heart
G
G
kidneys
brain
G
G
skin
bones/marrow
G
G
blood/fluids
tissue
G
G
arteries
eyes/cornea/lens
IV.
GENERAL PROVISIONS
a.
I understand that if I have been diagnosed as pregnant and that diagnosis is known
to my attending physician, this advance directive shall have no force or effect during
the course of my pregnancy.
b.
In the absence of my ability to give directions regarding the use of life-sustaining
procedures, it is my intention that this advance directive shall be honored by my
family and physicians as the final expression of my legal right to refuse medical or
surgical treatment including, but not limited to, the administration of life-sustaining
procedures, and I accept the consequences of such refusal.
c.
The advance directive shall be in effect until it is revoked.
d.
I understand that I may revoke this advance directive at any time.
e.
I understand and agree that if I have any prior directives, and if I sign this advance
directive, my prior directives are revoked.
f.
I understand the full importance of this advance directive and I am emotionally and
mentally competent to make this advance directive.
Signed this _____ day of ___________________, 20_____.
___________________________________________
(Signature)
___________________________________________
City of
___________________________________________
County, Oklahoma
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