Living Will Declaration
Declaration made this ________ day of _________, (20____), I ______________________________, willfully and
voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth
below, and I do hereby declare that, if at any time I am incapacitated and:
__________ (initial) I have a terminal condition, or
__________ (initial) I have an end state condition, or
__________ (initial) I am in a persistent vegetative state, and if my primary physician and another consulting physician
have determined that there is no reasonable medical probability of my recovery from such a condition, I direct that
life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only
to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of
medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to
alleviate pain.
It is my intention that this declaration be honored by my family and physician as the final expression of my legal right
to refuse medical or surgical treatment and to accept the consequences for such refusal.
In the event that I have been determined to be unable to provide express and informed consent regarding the
withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry
out the provisions of this declaration:
Name: _____________________________________________________________________________________
Address: ___________________________________________________________________________________
Phone: _____________________________________________________________________________________
I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
Additional Instructions (optional):
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Declarant’s Signature _______________________________________________ Date____/____/____
Witness __________________________________________________________ Date____/____/____
Witness __________________________________________________________ Date____/____/____
Florida Statue Ch. 765.303 Form #: H-00095B Revised 04/16