Name:

Street Address:

City and State: Zip Code:

Phone Number/Email: Fax Number:

Introduction Example: I, _____________________________ being of sound and disposing mind, memory and understanding, do hereby willfully and voluntarily make, publish and declare this statement as a directive to be followed if I become permanently unable to participate in decisions regarding my medical care. These instructions reflect my firm and settled commitment to decline medical treatment under the circumstances indicated below

Use example above

Use changes in text below.

It is common to include your birth date after your name in the introduction.

Yes, add birth date.

If yes, enter date below.

Do not add birth date.

Instruction Choices:

I direct:

My attending physician my family any other medical personnel

The selections above reflect your choice for withholding or not withholding treatment that serves only to prolong the process of dying, if you should be in an incurable or irreversible mental or physical state with no reasonable expectation of recovery.

Application of Instruction choices:

These instructions apply if I am:

in a terminal condition.

if my MD & another MD (providing a 2nd opinion) are in agreement that I have a terminal condition.

permanently unconscious or in a persistent vegetative state

brain dead diagnosed by scientific means.

if I am conscious but have irreversible brain damage & will never make decisions & express my wishes

Treatment choices:

If I am in the condition(s) described above, I feel especially strong about the following forms of treatment:

I do want cardiac resuscitation I do not want cardiac resuscitation

I do want mechanical respiration I do not want mechanical respiration

I do want tube feeding I do not want tube feeding.

Many people do not want continued treatment if the burdens of the treatment outweigh the expected benefits. This directive would state: I do not desire treatment to be provided and/or continued if the burdens of the treatment outweigh the expected benefits. Please indicate below it you would like this statement included.

Add the "burdens" statement. Do not add the "burdens" statement

Chemotherapy, Radiation Treatment, Dialysis, Blood Transfusions, and Antibiotic Treatments are some examples of "treatment measures" many people accept or do not accept as continued measures to prolong life. If you do accept these measures, the statements are simply not documented in the Living Will. Check only those that apply.

I do not desire Chemotherapy.

I do not desire Radiation Treatment.

I do not desire Antibiotic Treatment.

I do not desire Dialysis.

I do not desire Blood Transfusions.

I direct that:

Ending Example: I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration. I am under no constraint or undue influence. I hope you, who care for me, will feel morally bound to follow its mandates.

Use example above.

Use changes in text box below.

Please select either a Witness signature or a Notary signature. Usually notaries charge $5.00 for their service.

Witness Statement Notary

We can fax or mail your preliminary Mini Living Will. Please indicate below.

Fax: Please enter fax number above. Mail: Please enter mailing address above.

After you submit the choices form, your document will be compiled with your selections. Your Living Will can be faxed or mailed to you for your approval and for you to obtain witness signatures (two) or notary signature. Please mail or fax the signed document back for us to prepare the final document