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Free Living Will Form for California

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Preview - California Living Will Form

California Living Will Template

This document is designed for individuals in California who wish to outline their wishes regarding medical treatment if they become unable to communicate. This Living Will complies with California Probate Code Section 4701 et seq.

Please fill in the information as required.

PART 1: Personal Information

  • Full Name: ______________________________________
  • Date of Birth: ______________________________________
  • Address: ______________________________________

PART 2: Health Care Instructions

In the event that I, [Your Full Name], find myself in a terminal condition or an irreversible condition, I want the following:

  1. To receive no life-sustaining treatments (including but not limited to tubes or machines) that will not improve my chances of recovery.
  2. To be kept comfortable through palliative care as may be required.
  3. To refuse artificial nutrition and hydration if I am unable to swallow.

PART 3: Designation of Health Care Agent

I designate the following individual as my health care agent:

  • Name: ______________________________________
  • Phone Number: ______________________________________
  • Alternate Agent's Name: ______________________________________
  • Alternate Agent's Phone Number: ______________________________________

PART 4: Signatures

This Living Will takes effect only when I am unable to make my own health care decisions.

By signing below, I indicate that I understand the contents of this Living Will and that it reflects my wishes.

  • Signature: ______________________________________
  • Date: ______________________________________

Witnesses:

  • Witness 1 Signature: ______________________________________
  • Witness 1 Printed Name: _______________________________
  • Witness 2 Signature: ______________________________________
  • Witness 2 Printed Name: _______________________________
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