Fl-2521-Frm - Living Will Form printable pdf download

LIVING WILL

Declaration made this ____ day of ________________, 20___, I, ___________________________________

willfully and voluntarily make known my desires that my dying not be artificially prolonged under the

(principle),

circumstances set forth below, and I do hereby declare that, if at any time I am incapacitated

__________ I have a terminal condition

(initial)

or __________ I have an end-stage condition

(initial)

or __________ I am in a persistent vegetative state

(initial)

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withheld or withdrawn when the application of such procedures would serve only to prolong artificially the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 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 that 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: __________________________________________________________________________________

street address

city

state

zip code

Telephone: (________)_____________________

I understand the full import of this declaration, and I am emotionally and mentally competent to make this

declaration.

Additional Instructions: ______________________________________________________________________

_________________________________________________________________________________________

_______________________________

principle’s signature

X_________________________________________________________

X________________________________________________________

Witness Signature

_________________________________________________________

________________________________________________________

Print Name

___________________________________________________________

________________________________________________________

Street Address, City, State, Zip

___________________________________________________________

________________________________________________________

Telephone

The principle’s failure to designate a surrogate shall not invalidate the living will. [FS §765.303(2)]

FL-2521-FRM

provides this form pursuant to F.S. §765.303(1)

Fl-2521-Frm - Living Will Form

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