Living Will Form printable pdf download

Living Will Form

Living Will

You can make a Living Will by filling out this form. You can choose another form or use the one your doctor gives you. If you make a Living

Will, give it to your doctor. If you need help in understanding or filling out this form, please consult the doctor or a close family member.

I, (Print your name here) _______________________________________________, am of sound mind. I want to have what

I say here followed. I am writing this for when something happens to me, and I cannot make decisions about my medical care.

These instructions are to be used if I am not able to make decisions. I want my family and doctors to honor what I say here. These

instructions will tell what I want to have done if:

1) I am in a terminal condition (going to die), or

2) I am permanently unconscious and have brain damage that is not going to get better. If I am pregnant and my doctor knows it,

then my instructions here will not be followed during the time I am still pregnant and the baby is living.

TREATMENT I DO NOT WANT

If you DO NOT want the following put your initials by the services you DO NOT want.

______ Cardiac resuscitation (start my heart pumping after it has stopped)

______ Mechanical respiration (machine breathing for me if my lungs have stopped)

______ Tube feeding (a tube in my nose or stomach that will feed me)

______ Antibiotics (drugs that kill germs)

______ Hydration (water and other fluids)

______ Other (indicate what it is here) _______________________________________________________________________

_____________________________________________________________________________________________________

TREATMENT I DO WANT

If you DO want the following put your initials by the services you DO want.

______ Medical services

______ Pain relief

______ All treatment to keep me alive as long as possible

______ Other (indicate what it is here) _______________________________________________________________________

_____________________________________________________________________________________________________

What I indicate here will happen, unless I decide to change it or decide not to have a living will at all. I can change my living will

anytime I wish by letting my doctor know I want to change it or forgo a living will entirely.

Signature: __________________________________________________________________Date:_______________________

Address: ______________________________________________________________________________________________

Witness: __________________________________________________________________ Date:_______________________

TRI COUNTY OB GYN & WOMEN’S HEALTHCARE - G. L. BABALOLA, DO, FACOG

1602 NORTH SECOND STREET, SUITE C2, MILLVILLE, NJ 08332 - TEL: 856-765-3138 - FAX: 856-765-3147 -

Living Will Form