|  Next Page: Free Online Lease form. Free printable legal forms »

Free printable living will form

Living Will Sample

This is an example of a living will.  Please note there are different laws in each state and country, and we offer this only as an example.  We cannot offer any legal advice or represent that this sample form will work for your specific situation.   Also note that specific instructions within a living will can be adjusted for your own needs.  The text below can be copied and pasted into Word to create your own form.  You can also download free printable living will forms for males  and printable living will forms for females here.

DECLARATION

I,    ______________   , being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent.  This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below.

I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness.

I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment.

In addition, if I am in the condition described above, I feel especially strongly about the following forms of treatment:

I  ( )do   ( )do not  want cardiac resuscitation.

I  ( )do   ( )do not  want mechanical respiration.

I  ( )do   ( )do not  want tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water).

I  ( )do   ( )do not  want blood or blood products.

I  ( )do   ( )do not  want any form of surgery or invasive diagnostic tests.

I  ( )do   ( )do not  want kidney dialysis.

I  ( )do   ( )do not  want antibiotics.
——————————————————————————–

I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed previously, I may receive that form of treatment.
Other instructions:                                                                                                                       

I  ( )do  ( )do not  want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or in a state of permanent unconsciousness.

Name and address of surrogate (if applicable):                                                                            

Name and address of substitute surrogate (if surrogate designated above is unable to serve):        

I made this declaration on the                                day of                                       (month, year).

Declarant’s signature:                                                                                                                   

Declarant’s address:                                                                                                                     

The declarant or the person on behalf of and at the direction of the declarant knowingly and voluntarily signed this writing by signature or mark in my presence.

Witness’ signature:                                                                                                                       

Witness’ address:                                                                                                                         

Witness’ signature:                                                                                                                        

Witness’ address:                                                                                                                         

Page topic: Download Free printable living will form online

  |  Next Page: Free Online Lease form. Free printable legal forms »

COMMENT (Not all comments are approved, including rude comments and those with strong language).

Section: Free Legal Forms