Advance Directive For Medical / Surgical Treatment (Living Will) (Page 3 of 3) in pdf

IV. CONSULTATION WITH OTHER

VIII. DECLARATION OF WITNESSES

PERSONS

This declaration was signed by (name of Declarant)

I authorize my healthcare providers to discuss my

in our presence, and we, in the presence of each other,

condition and care with the following persons, under

and at the Declarant’s request, have signed our names

standing that these persons are not empowered to make

below as witnesses. We declare that, at the time the

any decisions regarding my care, unless I have appointed

Declarant signed this declaration, we believe that he or

them as my Healthcare Agents under Medical Durable

she was of sound mind and under no pressure or undue

Power of Attorney.

influence. We did not sign the Declarant’s signature. We

Name

Relationship

are not doctors or employees of the attending doctor or

healthcare facility in which the Declarant is a patient.

We are neither creditors nor heirs of the Declarant and

have no claim against any portion of the Declarant’s

estate at the time this declaration was signed. We are at

least eighteen (18) years old and under no pressure,

undue influence, or otherwise disqualifying disability.

V. NOTIFICATION OF OTHER PERSONS

Signature of Witness

Before withholding or withdrawal life-sustaining

procedures, my healthcare providers shall make a

Printed Name

reasonable effort to notify the following persons that I

am in a terminal condition or Persistent Vegetative State.

Address

My healthcare providers have my permission to discuss

my condition with these persons. I do NOT authorize

these persons to make medical decisions on my behalf,

unless I have appointed one or more of them as my

Agent(s) under Medical Durable Power of Attorney.

Signature of Witness

Name

Telephone number or email

Printed Name

Address

Notary Seal (optional)

VI. ANATOMICAL GIFTS

State of ___________________________

County of

}

(Initials) I wish to donate my (check one or both)

____ organs and/or ____ tissues, if medically possible.

SUBSCRIBED and sworn to before me by

(Initials) I do not wish donate my organs or tissues.

, the Declarant,

VII. SIGNATURE

and

I execute this declaration, as my free and voluntary act,

and

this

day of

, 20

witnesses, as the voluntary act and deed of the Declarant

this day of

, 20

Declarant signature

Notary Public

My commission expires:

Pursuant to Colorado Revised Statute 15-18.101–113

Advance Directive For Medical / Surgical Treatment (Living Will) Page 3

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