Living Will Form

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Living Will
Declaration made this _________ day of ____________ , 20______ I, __________________________ , 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
_____(initial) and I have a terminal condition
or _____(initial) and I have an end-state condition
or _____(initial) and I am in a persistent vegetative state
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withdrawn when the application of such procedures would serve only to prolong artificially the process of dying,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 necessarily to provide me with comfort care or to alleviate pain.
I do ____, I do not ____ desire that nutrition and hydration (food and water) be withheld or withdrawn when the
application of such procecures would serve only to prolong artifically the process of dying.
It is my intention that this declaration be honored by my family and physician 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 I have been determined to be unable to provide express 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:
___________________________________________________________________
Address:
___________________________________________________________________
_________________________________________________ Zip Code___________
Phone: _______________________________________________________________
I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
Additional Instructions (optional):______________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(Signed) ________________________________________
__________________________________
___________________________________
(Witness)
(Witness)
__________________________________
___________________________________
(Address)
(Address)
__________________________________
___________________________________
(City, State, Zip)
(City, State, Zip)
__________________________________
___________________________________
(Phone)
(Phone)
(At least one witness must be neither a spouse nor a blood relative of the signatory.)

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