FREE LIVING WILL FORM SAMPLE Blank Printable Template
A living will form is a written document stating the wishes of the signer regarding medical treatment, if he or she becomes terminally ill, unable to communicate or mentally incompetent.
The will also protects the medical team or hospital from liability for withdrawing or limiting life support of a terminal patient.
A living will form is necessary in order to instruct your physician to make decisions whether to maintain or stop life support when you are:
Unconscious, in a coma, or in a persistent vegetative state (over 48 hours) with almost no chance to regain consciousness
Terminally ill, without any chance of recovering
Unable to communicate
Unable to make your own health care decisions
In a situation where the probable risks and burdens of treatment would outweigh the expected benefits.
The executor of a living will must:
Be 18 years of age or older
Be mentally competent
The executor of a living will form cannot:
Be any person you owe money to
Be your health care provider
Be one of the employees of your health care provider
Be the operator or employee of a residential care facility for the elderly or community facility
Be anyone that could have a reason to believe he or she will have something to gain after your death
LIVING WILL FORM
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 provide, withhold, or withdraw medical treatment in accordance with the choice I have marked below:
(a) Choice NOT TO Prolong Life
[ ]I do not want my life to be prolonged under any of the following conditions, determined by two or more physicians: Incurable and Irreversible condition, Permanent Unconsciousness, Risky Treatment. (strike any wording you do not want.)
(b) Choice TO Prolong Life
[ ]I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.
[ ]I direct that treatment for alleviation of pain or discomfort should be provided at all times even if it hastens my death.
DESIGNATION OF AGENT: I , ______________________________, designate the following person as my agent to make health care decisions for me:
(Name of person chosen as agent)
(City, State and Zip code)
(Home or Cell Phone)
DONATION OF ORGANS AT DEATH (OPTIONAL)
Upon my death: (mark applicable box)
[ ] (a) I give any needed organs, tissues, or parts, OR
[ ] (b) I give the following organs, tissues, or parts only: _________________________
[ ] (c) My gift is for the following purposes: __Transplant __Education __Research __Therapy
PRIMARY PHYSICIAN: (OPTIONAL)
I designate the following physician as my primary physician:
Name of Physician: ____________________________
EFFECT OF COPY: A copy of this form has the same effect as the original.
I am emotionally and mentally competent to make this declaration, and I understand the full import of this declaration.
I reserve the right to revoke this living will form at any time.
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)
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 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.
I further declare that 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.
Signed at __________________ on this ____ day of _________________, 20____.
(Name and address of first witness)
(Name and address of second witness)
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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