Florida Living Will Form printable pdf download

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

, 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

(initial) I have a terminal condition.

(initial) I have an end stage condition.

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withheld or withdrawn when the application of such procedures would serve only to prolong artificially the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

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

Street Address

City, State& Zip

City, State & Zip

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

Florida Living Will Form