Living Will And Health Care Surrogate Designation Forms (Page 2 of 4) in pdf

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life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only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):

___________________________________________________________________________________________

Declarant’s Signature _______________________________________________ Date____/____/____

Witness __________________________________________________________ Date____/____/____

Florida Statue Ch. 765.303 Form #: H-00095B Revised 04/16

Living Will And Health Care Surrogate Designation Forms Page 2