Living Will Form

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Suggested form of a Living Will, Florida Statutes Section 765.303
A living will may, BUT NEED NOT, be in the following form:
Living Will
Declaration made this
day of
2
, 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 incapacitated and
I have a terminal condition.
or
I have an end stage condition.
or
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withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and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 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
City
State
Zip
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
Street Address
Street Address
City, State & Zip
City, State & Zip
Phone
Phone
The principal’s failure to designate a surrogate shall not invalidate the living will.
— This form offered as a courtesy of The Florida Bar and the Florida Medical Association —
04/05

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