Living Will Template
This Living Will is designed to help you express your wishes regarding medical treatment in accordance with your state's laws.
Patient Information:
- Name: ________________________
- Date of Birth: __________________
- Address: _______________________
Health Care Declaration:
I, __________________________, being of sound mind, hereby declare that if I am unable to communicate my wishes regarding medical treatment due to illness or injury, I want the following wishes to be honored:
- In the event of a terminal condition, I do not wish to receive life-sustaining treatment that would only prolong the dying process.
- If I am in a persistent vegetative state or a state deemed irreversible by my attending physician, I do not want any artificial means of sustaining my life.
- I would like my care to focus on my comfort and dignity, rather than prolonging life at all costs.
Nomination of Health Care Proxy:
If necessary, I appoint the following individual to make health care decisions on my behalf:
- Name of Proxy: ___________________
- Relationship: ______________________
- Contact Information: ______________
Signatures:
Patient Signature: ____________________________ Date: _______________
Witness Signature: ____________________________ Date: _______________
Please ensure that you comply with your state laws regarding Living Wills and the witnessing of signatures.