Fillable Wyoming Advance Health Care Directive Form (Page 5 of 7) in pdf

Wyoming Advance Health Care Directive Form Page 5

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Print your full name: ______________________________________________________________________

Today’s date: _________________________ Initial that you have completed the page: ______

(7) Relief from pain:

Check

Initial

___

I want treatment for the alleviation of pain or discomfort at all times;

___

I do NOT want treatment for the alleviation of pain or discomfort.

(8) Other wishes: (If you do not agree with the choices above, you may write your

own or add to the instructions above. Examples may include: blood or blood products;

chemotherapy; simple diagnostic tests; invasive diagnostic tests; minor surgery; major

surgery; antibiotics; oxygen; wish to die at home if possible; etc.) I direct that:

______________________________________________________________________

PART 3: DONATION OF ORGANS AND TISSUES UPON DEATH

(9) Upon my death (check and initial applicable boxes):

Check

Initial

___

(a) I have arranged to give my body to

science.

___

(b) I have arranged through the Wyoming Donor Registry to give any

needed organs and/or tissues (For enrollment information, call

1-888-868-4747 or visit ).

___

Wyoming Advance Health Care Directive Form Page 5

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