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:
The executor of a living will must:
The executor of a living will form cannot:
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
(b) Choice TO Prolong Life
DESIGNATION OF AGENT: I , ______________________________, designate the following person as my agent to make health care decisions for me:
DONATION OF ORGANS AT DEATH (OPTIONAL)
Upon my death: (mark applicable box)
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 __________________.
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 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____.
State 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.