Illness And Hospitalization Living Will Form printable pdf download

Illness and Hospitalization

Living Will Form

LIVING WILL DECLARATION OF _________________________.(Print)

To my family, doctors, hospitals, surgeons, medical care providers, and others concerned with my care:

I, ______________________________________, being of sound mind and rational thought willfully and

voluntarily make this declaration to be followed if I become incompetent or incapacitated to the extent

that I am unable to communicate my wishes, desires, and preferences on my own.

This declaration reflects my firm, informed, and settled commitment to refuse life-sustaining medical care

and treatment under the circumstances that are indicated below.

This declaration and the following directions are an expression of my legal right to refuse medical care

and treatment. I expect and trust the above-mentioned parties to regard themselves as legally and

morally bound to act in accordance with my wishes, desires, and preferences. The above-mentioned

parties should therefore be free from any legal liabilities for having followed this declaration and the

directions that it contains.

If I should stop breathing or my heart should stop: (Please check one)

I DO WISH TO BE FULLY RESUSITATED (CPR)___________________

I DO NOT WISH TO BE RESUSITATED (CPR)__________________

This Living Will Declaration expresses my firm wishes, desires, and preferences and the fact that I may

have executed a form by the law of the State of Arizona, may not be used a limiting or contradicting this

Living Will Declaration, which is an expression of both my common law and constitutional rights.

I make this Living Will Declaration the _________day of ________, 20___.

_________________________________________

Declarant’s Signature

________________________________________

Declarant’s Address

***If you already have a living will please attach to this form.

***If at any time you change your living will, please send a signed and updated copy to our office.

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Illness And Hospitalization Living Will Form