OKLAHOMA STATUTES TITLE 63 SECTION 3103

DIRECTIVE TO PHYSICIANS

Directive made this _________________ day of ___________.

I _______________, being of sound mind and twenty-one years of

age or older, willfully and voluntarily make known my desire that

my life shall not be artificially prolonged under the

circumstances set forth below, and do hereby declare:

1. If at any time I should have an incurable irreversible

condition caused by injury, disease, or illness certified to be a

terminal condition by two physicians, I direct that life-

sustaining procedures be withheld or withdrawn and that I be

permitted to die naturally, if the application of life-sustaining

procedures would serve only to artificially prolong the moment of

my death and where my physician determines that my death is

imminent whether or not life-sustaining procedures are utilized;

2. In the absence of my ability to give directions regarding the

use of such life-sustaining procedures, it is my intention that

this directive shall be honored by my family and physician(s) as

the final expression of my legal right to refuse medical or

surgical treatment and accept the consequences of such refusal;

3. If I have been diagnosed as pregnant and that diagnosis is

known to my physician, this directive shall have no force or

effect during the course of my pregnancy;

4. I have been diagnosed and notified as having a terminal

condition by _____________________, M.D. or D.O. whose address is

________________, I understand that if I have not filed in the

name and address of the physician, it shall be presumed that I

did not have a terminal condition when I made out this directive;

5. This directive shall be in effect until revoked;

6. I understand the full import of this directive and I am

emotionally and mentally competent to make this directive; and

7. I understand that I may revoke this directive at any time.

Signed _________________________________________________

The declarant has been personally known to me and I believe him

or her to be of sound mind. I am twenty-one (21) years of age or

older, I am not related to the declarant by blood or marriage,

nor would I be entitled to any portion of the estate of the

declarant upon the death of the declarant, nor am I the attending

physician or directly financially responsible for declarant's

medical care, or any person who has a claim against any portion

of the estate of the declarant upon the death of the declarant.

________________________________________________________________

WITNESS

________________________________________________________________

WITNESS

State of Oklahoma)

County of _____________________)

Before me, the undersigned authority, on this day personally

appeared ______________________ declarant, _____________________

witness and ________________________________ witness whose names

are subscribed to the foregoing instrument in their respective

capacities, and, all of said persons being by me duly sworn, the

declarant declared to me and to the said witnesses in my presence

that said instrument is his or her "Directive to Physicians", and

that the declarant had willingly and voluntarily made and executed

it as the free act and deed of the declarant for the purposes

therein expressed.

The foregoing instrument was acknowledged before me this

___________________ day of ______________________, 19__________.

Signed:

__________________________________________________________

Notary Public in and for ____________ County, Oklahoma

My Commission Expires: