A living will form allows your agent or guardian you appoint to make Health Care decisions for you.
Your agent can decide as to accept or reject life support or surgical medical treatment if you are terminally ill, incapacitated, permanently unconscious or unable to communicate at that time.
In this document you can specify whether life-prolonging medical or surgical procedures are to be continued, or withheld or withdrawn, also if artificial feeding and fluids are to be used or withheld.
Only one person may be named the Health Care Agent at a time. Usually it is a close family member like, wife or husband, son or daughter, or any other trustworthy person you desire who must willingly assume the responsibility of being your representative in these matters.
A Living Will form can be revoked by you prior to becoming incapacitated.
Some States require the living will form or medical power of attorney to have witnesses at the time of signature or that the document be signed in the presence of a Notary public, or both. This is a generic form that contains space for signing of witness and notary public. Make sure your living will form document complies with the laws of your State.
It is estimated that about 60% of United States Residents still do not have a Living Will.
Below is an example/template of free blank living will form or medical power of attorney.
INSTRUCTIONS FOR HEALTH CARE
I, _______________________, of _______________________, being of sound mind, do hereby willfully and voluntarily make known my desire that my health care providers and others involved in my care withdraw, withhold, or provide medical treatment in accordance with the choice I have marked below:
In the event that I am unable to communicate and diagnosed to be in a terminal or permanent unconscious condition with no hope of recovery I want to receive life sustaining treatment. ___ Yes ___ No
In the event that I am in a terminal or permanent unconscious condition, in severe pain, and unable to communicate, I would like to receive any and all pain medication even if the administration of it may lead to permanent physical damage, or addiction, or hasten the time of your death. ___ Yes ___ No
In the event that I am unable to communicate and diagnosed to be in a terminal or permanent unconscious condition with no hope of recovery, I want to receive artificially provided food and water. ___ Yes ___ No
DESIGNATION OF AGENT. I , ______________________________, designate the following person as my agent to make health care decisions for me:
Primary Agent _____________________________
Full Name (First and Last) _____________________________
Agent's relationship to you _____________________________
Street Address _____________________________
City and State _____________________________
Zip code _____________________________
Alternate Agent _____________________________ (Optional)
Agent will be able to consent or refuse psychiatric care. ___ Yes ___ No
Agent will be able to make funeral decisions and arrangements on my behalf. ___ Yes ___ No
Agent will be able to authorize an autopsy. ___ Yes ___ No
Agent will be able to donate my organs for transplant. ___ Yes ___ No
Agent will be able to donate my organs/body for scientific research. ___ Yes ___ No
PRIMARY PHYSICIAN (OPTIONAL)
I designate the following physician as my primary physician:
Name of Physician: ____________________________ Phone: (____)_____________
NON-FAMILY MEMBERS. I wish a non-family member such as a committed life partner to have first priority in visitation, this will protect his or her visitation rights.
Partner's or Friend's Full Name _____________________________
Relationship to me _____________________________
EFFECT OF COPY: A copy of this form has the same effect as the original.
STATEMENT OF WITNESSES
I declare under penalty of perjury under the law that the individual who signed or acknowledged this living will is personally known to me, and I believe him/her to be of sound mind and under no duress, fraud, or undue influence, and emotionally and legally competent to make the herein Health Care Directive to Physicians. I am not related to the declarant by blood, marriage, or adoption, and, to the best of my knowledge, nor would I have any claim or be entitled to any portion of the declarant's estate upon his/her death.
I further declare that I am not a person appointed as agent by this advance directive, and I am not the individual’s health care provider, nor an employee of the individual's health care provider, nor the operator or employee of a community health care facility, nor the operator or the employee of a residential care facility for the elderly.
Signed at __________________ on this ____ day of _________________, 20____.
(Name and address of first witness)
(Name and address of second witness)
I am emotionally and mentally competent to make this declaration, and I understand the full import of this declaration.
I execute this declaration, as my free and voluntary act, on this ___________ day of _______________, 20___, in the City of ___________________________, County of __________________, State of __________________.
(Sign your name)
(Print your name)
(City, state, zip)
I reserve the right to revoke this living will form at any time.
State of _____________________ )
County of ___________________ )
On _______________________ before me, _________________________________, (name of notary public) personally appeared ________________________________,(name of principal) personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same in his/her authorized capacity and that by his/her signature on the instrument the person upon behalf of which the person acted, executed the instrument.
WITNESS my hand and official seal.
Signature of notary
Notary Public for ___________________________ My commission expires: ____/____/_____ NOTARY SEAL
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