Fillable Living Will Form

Living Will for [State Name]

This Living Will is designed to help you express your medical wishes as you wish to outline them according to the laws of [State Name]. Please complete the sections below to ensure that your preferences are clearly communicated.

Individual Information:

• Full Name: _______________________________
• Date of Birth: _______________________________
• Address: _______________________________
• City: _______________________________
• State: _______________________________
• Zip Code: _______________________________
• Phone Number: _______________________________

Healthcare Agent Information:

• Name: _______________________________
• Relationship: _______________________________
• Phone Number: _______________________________
• Address: _______________________________

Medical Preferences:

Please indicate your preferences regarding life-sustaining treatment in the following situations:

1. If I am in a terminal condition:
   • □ I wish to receive all available treatment.
   • □ I do not wish to receive life-sustaining treatment.
2. If I am in a persistent vegetative state:
   • □ I wish to receive all available treatment.
   • □ I do not wish to receive life-sustaining treatment.
3. If I have an advanced medical condition:
   • □ I wish to receive all available treatment.
   • □ I do not wish to receive life-sustaining treatment.

Signature: _______________________________

Date: _______________________________

Witnesses: Two witnesses are needed.

• 1. _______________________________ (Signature & Name)
• 2. _______________________________ (Signature & Name)

Please review your Living Will periodically to ensure it continues to reflect your wishes.