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Advance Directive For Health Care

ADVANCE DIRECTIVE FOR HEALTH CARE

(Living Will and Health Care Proxy)

This form may be used in the State of Alabama to make your wishes known

about what medical treatment or other care you would or would not want if you

become too sick to speak for yourself. You are not required to have an advance

directive. If you do have an advance directive, be sure that your doctor, family,

and friends know you have one and know where it is located.

Section 1. Living Will

I, ___________________, being of sound mind and at least 19 years old,

would like to make the following wishes known. I direct that my family, my

doctors and health care workers, and all others follow the directions I am

writing down. I know that at any time I can change my mind about these

directions by tearing up this form and writing a new one. I can also do away

with these directions by tearing them up and by telling someone at least 19

years of age of my wishes and asking him or her to write them down.

I understand that these directions will only be used if I am not able to speak for

myself.

IF I BECOME TERMINALLY ILL OR INJURED:

Terminally ill or injured is when my doctor and another doctor decide that I

have a condition that cannot be cured and that I will likely die in the near future

from this condition.

Life sustaining treatment - Life sustaining treatment includes drugs, machines,

or medical procedures that would keep me alive but would not cure me. I know

that even if I choose not to have life sustaining treatment, I will still get

medicines and treatments that ease my pain and keep me comfortable.

Place your initials by either "yes" or "no":

I want to have life sustaining treatment if I am terminally ill or injured.

____ Yes ____ No

Advance Directive For Health Care