This is a required section which briefly explains the effect which this document will have on the Declarant. Press [Ctrl+F1] for more information.
This is a required section in which the Declarant (the person the Living Will is prepared for) states his/her intention to make a Living Will. Press [Ctrl+F1] for more information.
This is a required section in which the Declarant chooses which treatments he/she would or would not like to have. Press [Ctrl+F1] for more information.
This is a required section in which the Declarant states whether artificially administered nutrition and hydration should be withheld or withdrawn. Press [Ctrl+F1] for more information.
This optional section states what effect should be given to the Living Will if the Declarant is pregnant. Press [Ctrl+F1] for more information.
This is an optional section which allows for additional specific instructions and requests. Press [Ctrl+F1] for more information.
This recommended provision provides that the inclusion of an invalid request of instruction does not invalidate the other provisions. Press [Ctrl+F1] for more information.
This required section provides the signature line for the Declarant who must sign in the presence of witnesses and a Notary Public. Press [Ctrl+F1] for more information.
This required section provides the signature line for the witnesses in accordance with the state law requirements. Press [Ctrl+F1] for more information.
This is a required section in which a public official (such as a Notary Public) acknowledges the signatures of the Declarant and the witnesses. Press [Ctrl+F1] for more information.
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Living Will
LIW_SD
The Living Will is a document under which a competent adult, prior to becoming unconscious or incompetent, declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances.
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. A Living Will directs the Declarant's physician to withdraw or withhold life-sustaining procedures if the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information.
WSD01
! Disclosure Section (1 of 10)
LIVING WILL DECLARATION
This is an important legal document. This document directs the medical treatment you are to receive if you are unable to participate in your own medical decisions and you are in a terminal condition. This document may state what kind of treatment you want or do not want to receive.
This document can control whether you live or die. Prepare this document carefully. If you use this form, read it completely. You may want to seek professional help to make sure the form does what you intend and is completed without mistakes.
This document will remain valid and in effect until and unless you revoke it. Review this document periodically to make sure it continues to reflect your wishes. You may amend or revoke this document at any time by notifying your physician and other health-care providers. Please note that this document provides signature lines for you, the two witnesses whom you have selected, and a notary public.
This required section states the basic purposes for this document as well as the importance of understanding every section. Press [Ctrl+F1] for more information on Living Wills.
WSD02
! Declaration Section (2 of 10)
TO MY FAMILY, PHYSICIANS, AND ALL THOSE CONCERNED WITH MY CARE:
I, !, willfully and voluntarily make this declaration as a directive to be followed if I am in a terminal condition (including a condition of permanent unconsciousness) and become unable to participate in decisions regarding my medical care.
With respect to any life-sustaining treatment, I direct the following:
A Living Will is prepared for a "Declarant". In this required section, the Declarant states his/her intentions regarding life-sustaining procedures or treatment during terminal and/or coma circumstances.
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. A Living Will directs the Declarant's physician to withdraw or withhold life-sustaining procedures if the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information.
WSD03
! Treatment Section (3 of 10)
(Initial only one of the following optional directives if you agree. If you do not agree with any of the following directives, space is provided below for you to write your own directives.)
_______ (initials) NO LIFE-SUSTAINING TREATMENT. I direct that no life-sustaining treatment be provided. If life-sustaining treatment is begun, terminate it.
_______ (initials) TREATMENT FOR RESTORATION. Provide life-sustaining treatment only if and for so long as you believe treatment offers a reasonable possibility of restoring to me the ability to think and act for myself.
______ (initials) TREAT UNLESS PERMANENTLY UNCONSCIOUS. If you believe that I am permanently unconscious and are satisfied that this condition is irreversible, then do not provide me with life-sustaining treatment, and if life-sustaining treatment is being provided to me, terminate it. If and so long as you believe that treatment has a reasonable possibility of restoring consciousness to me, then provide life-sustaining treatment.
_______ (initials) MAXIMUM TREATMENT. Preserve my life as long as possible, but do not provide treatment that is not in accordance with accepted medical standards as then in effect.
_______ (initials) ! ! ! ! ! !
This required section describes the circumstances under which you, the Declarant, want to have life-sustaining procedures or treatment withheld or withdrawn if you become terminally ill or permanently unconscious. Press [Ctrl+F1] for more information.
If none of the above options describes your wishes, use this space to enter your own specific directives regarding the use of life-sustaining treatment.
WSD04
! Nutrition Section (4 of 10)
(Artificial nutrition and hydration is food and water provided by means of a nasogastric tube or tubes inserted into the stomach, intestines, or veins. If you do not wish to receive this form of treatment, you must initial the statement below which reads: "I intend to include this treatment among the "life-sustaining treatment" that may be withheld or withdrawn.")
With respect to artificial nutrition and hydration, I wish to make clear that: (initial only one)
_______ (initials) I intend to include this treatment among the "life-sustaining treatment" that may be withheld or withdrawn.
_______ (initials) I do not intend to include this treatment among the "life-sustaining treatment" that may be withheld or withdrawn.
This required section enables the Declarant to specify whether or not he/she intends to include artificial nutrition and hydration among the life-sustaining procedures and treatments to be withheld or withdrawn. Press [Ctrl+F1] for more information.
LNJ04
! Optional Pregnancy Section (5 of 10)
If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy.
! [Optional additional sentence] However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining treatment, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If life-sustaining treatment will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.
Enter an X to include a pregnancy paragraph which states that this Living Will will not be enforced if you are pregnant. Certain exceptions to this statement are presented. Press [Ctrl+F1] for more information.
Enter an X to provide an exception to the invalidity of the Living Will if you are pregnant. This exception permits enforcement of the Living Will if the fetus could not develop to the point of live birth with the continued application of life-sustaining treatment.
Enter an X to provide an exception to the invalidity of the Living Will if you are pregnant. This exception requests that pain or physical harm to you be considered in determining whether life-sustaining treatment should be withheld or withdrawn.
LAL05
! Optional Other Specific Requests Section (6 of 10)
Other specific requests:
Enter an X to include a paragraph that allows you to state other specific requests or instructions.
Use this space to state any other specific requests or instructions.
LAL06
! Optional Severability Section
If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
It is recommended that this severability provision be included to prevent one invalid provision from invalidating the entire document. However, if you do not want to include it, press the spacebar to deselect the checkbox. Press [Ctrl+F1] for information regarding the reasons for including a severability paragraph.
WSD08
! Declarant Signature Section (8 of 10)
Dated this _____ day of _______________, 19___.
________________________________________
Signature
Declarant Name: !
Declarant Address:City: !
State: !
! Country: !
! SSN: !
! Birthdate: !
This required section provides a signature line for the Declarant, and requests additional information regarding the Declarant. The date of the document should be entered on the blank lines at the time the document is signed.
Enter the Declarant's city or edit the information as desired.
Enter the Declarant's state/province or edit the information as desired.
Enter an X to include the country in which the Declarant resides, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Declarant's social security number (SSN). By providing the SSN, the health care providers will be assisted in maintaining their Living Will files. Press [Ctrl+F1] for more information.
Enter the Declarant's social security number or edit the information as desired.
Enter an X to include the Declarant's date of birth. By providing the date of birth, the health care providers will be assisted in maintaining their Living Will files. Press [Ctrl+F1] for more information.
Using the format MM/DD/YYYY, enter the Declarant's date of birth or edit the information as desired.
WSD09
! Witness Signature Section (9 of 10)
The Declarant voluntarily signed this document in my presence. I am at least 18 years of age.
This required section provides signature lines for the witnesses, and requests additional information regarding the witnesses.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed. Press [Ctrl+F1] for more information.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
WSD10
! Notary Section (10 of 10)
[This is a required section in which a Notary Public acknowledges that the Declarant and Witnesses signed the document.]
On this _____ day of _______________, 19___, the Declarant, !, and witnesses, _______________________________and _________________________________ personally appeared before the undersigned officer and signed the foregoing instrument in my presence.
Dated this _____ day of _______________, 19___.
________________________________________
Notary Public
My commission expires: ________________
This is a required section in which a Notary Public acknowledges that the witnesses and the Declarant signed this document. Press [Ctrl+F1] for more information.
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