Living Will

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Living Will

Who is completing this document?

* Indicates required field

Name *

First

Last

City *

County *

Sate *

Birthday (Month/Day/Year) *

What kind of health care directives do you want to give? *

Directives about end-of-life treatment (Living Will) Designation of another person to make health care decisions for your (Health Care Power of Attorney) Both (Advance Directive)

Select the appropriate option. Depending on your selection, you will either create a Living Will, Health Care Power of Attorney, or a document that combines features of both, sometimes referred to as an Advance Directive. The document's title will depend on your selection and your state's law.

If you have a terminal condition and are expected to die within six months, should life-sustaining treatment be withheld and withdrawn? *

Yes No

Select "Yes" if you want life-sustaining treatment to be withheld and withdrawn if you have a terminal condition and are expected to die within six months. Otherwise, select "No." CAUTION: YOU MUST INITIAL THE STATEMENTS ABOUT LIFE-SUSTAINING TREATMENT ON THE DOCUMENT.

If you have an irreversible condition, cannot care for yourself or make decisions for yourself, and will die without life-sustaining treatment, should life-sustaining treatment be withheld and withdrawn? *

Yes No

Select "Yes" if you want life-sustaining treatment to be withheld and withdrawn if you have an irreversible condition, cannot care for yourself or make decisions for yourself, and will die without life-sustaining treatment. Otherwise, select "No." CAUTION: YOU MUST INITIAL THE STATEMENTS ABOUT LIFE-SUSTAINING TREATMENT ON THE DOCUMENT.

Will a statement regarding artificially provided food and fluids be included? *

Yes No

Select "Yes" to include a provision regarding whether artificially administered nutrition and hydration will be provided, even though there is no hope of recovery from your condition.

Do you want to receive artificially provided food and fluids? *

Yes, I wish to receive No, I do not wish to receive

Select "Yes" if you WISH TO RECEIVE artificially administered nutrition and hydration, even though there is no hope of recovery from your condition.

What other specific requests or instructions do you wish to make? *

Enter any other specific requests or instructions.

How will this document be finalized? *

Signed in front of a Notary Public Signed in front of 2 witnesses Signed in front of BOTH a Notary Public and 2 witnesses

In order to be legal this document must either be signed in the presence of two witnesses or a notary public. We recommend you sign the document BOTH in the presence of two witnesses AND a notary public.

Who is the first Witness? (if applicable) *

You may enter the witness information now or when the document is signed. CAUTION: Carefully review and comply with the limits on who may be a witness that are printed on the document.

Address *

City *

State *

Zip Code *

Who is the second Witness? (if applicable) *

Address *

City *

State *

Zip Code *

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