Fill and Sign the Health Declaration Form

DECLARATION AS TO MEDICAL OR SURGICAL TREATMENT (CRS 15-18-104.) I, _________________________ , (name of declarant), being of sound mind and at least eighteen years of age, direct that my life shall not be artificially prolonged under the circumstances set forth below and hereby declare that: 1. If at any time my attending physician advanced practice nurse and one other qualified physician or advanced practice nurse certify in writing that: a. I have an injury, disease, or illness which is not curable or reversible and which, in their judgment, is a terminal condition, and b. For a period of seven consecutive days or more, I have been unconscious, comatose, or otherwise incompetent so as to be unable to make or communicate responsible decisions concerning my person, then I direct that, in accordance with Colorado law, life-sustaining procedures shall be withdrawn and withheld pursuant to the terms of this declaration, it being understood that life-sustaining procedures shall not include any medical procedure or intervention for nourishment considered necessary by the attending physician to provide comfort or alleviate pain. However, I may specifically direct, in accordance with Colorado law, that artificial nourishment be withdrawn or withheld pursuant to the terms of this declaration. 2. In the event that the only procedure I am being provided is artificial nourishment, I direct that one of the following actions be taken: _______ (initials of declarant) a. Artificial nourishment shall not be continued when it is the only procedure being provided; or _______ (initials of declarant) b. Artificial nourishment shall be continued for _________ days when it is the only procedure being provided; or _______ (initials of declarant) c. Artificial nourishment shall be continued when it is the only procedure being provided. (Optional) I hereby make an anatomical gift, to be effective upon my death, of: A. _______ Any needed organs/tissues OR B. _______ The following organs/tissues: _____________________________ _____________________________ _____________________________ Donor signature: ___________________________________________ 3. I execute this declaration, as my free and voluntary act, this _____ day of ____________________ , 20 _____ . By___________________________ Declarant The foregoing instrument was signed and declared by _________________________ to be his/her declaration, in the presence of us, who, in his/her presence, in the presence of each other, and at his/her request, have signed our names below as witnesses, and we declare that, at the time of the execution of this instrument, the declarant, according to our best knowledge and belief, was of sound mind and under no constraint or undue influence. We further declare that neither of us is : 1) a physician; 2) the declarant’s physician or an employee of his/her physician; 3)an employee or a patient of the health care facility in which the declarant is a patient; or 4) a beneficiary or creditor of the estate of the declarant . Dated at, Colorado, this _____ day of _____________ , 20 _____ . ___________________________________ ___________________________________ Name Name ___________________________________ ___________________________________ Address Address OPTIONAL STATE OF COLORADO ) ) ss. County of ______________ ) SUBSCRIBED and sworn to before me by _______________ , the declarant, and __________________ and _____________________ , witnesses, as the voluntary act and deed of the declarant this _____ day of ________________ , 20 _____ . My commission expires: _________________________ Notary Public