Fillable Florida Living Will Form printable pdf download

Suggested form of a Living Will, Florida Statutes Section 765.303

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 mentally or physically incapacitated and

_______(initial) I have a terminal condition.

or _______(initial) I have an end stage condition.

or _______(initial) 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withheld or withdrawn when the application of such procedures would serve only to prolong artificially the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.

I do___, I do not ___desire that nutrition and hydration (food and water) be withheld or withdrawn when the

application of such procedures would serve only to prolong artificially 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 _______________________________________________________________

Street 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 ______________________________________

At least one witness must not be a husband or wife or a blood relative of the principal.

— This form offered as a courtesy of The Florida Bar and the Florida Medical Association —

Florida Living Will Form