Fill and Sign the Living Will Form 481370378

LIVING WILL (Florida Statutes 765-303) 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 he reby declare that, if at any time I am incapacitated and (initial as applicable) _____ I have a terminal condition _____ I have an end-stage condition _____ I am in a persistent vegetative state and if my attending or treating physician and another consulting physician have determi ned that there is no reasonable medical probability of my recovery from such condition, I direct tha t life- prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the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 t he 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: _______________________________________________________ City, State: _______________________________________________________ Zip Code: __________ Phone: ___________________________ I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration. Additional instructions (optional): _____________________________________________________________________________ Name: ________________________________________ Signed: Date: ___________________________ Witnesses: 1. Signature: Printed Name: ____________________________________________ Address: ____________________________________________ 2. Signature: Printed Name: ____________________________________________ Address: ____________________________________________