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Free Fillable Advance Directive Form

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Name of Grantor
Full Address of Grantor
Name of 1st Agent
1st Agent Number
1st Agent Full Address
Name of 2nd Agent
2nd Agent Number
2nd Agent Full Address
Information not to be released


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ADVANCE HEALTH CARE DIRECTIVE

 

 

Name: ________________________

 

Address: ______________________

______________________________

 

PART 1.  Durable Power of Attorney for Health Care

 

I hereby appoint the following person to act as my agent and to make decisions about my medical care on my behalf.

 

Name:

 

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Telephone:

 

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Address:

 

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If for any reason whatsoever, I revoke my agent's authority or if my agent is not willing, able, or available to make a health care decision for me, I designate as my first alternate agent

 

Name:

 

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Telephone:

 

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Address:

 

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I hereby declare that I have not appointed any other person to make any health care decisions on behalf of me in any other document. 

 

My agent is authorized to:

 

(a) make all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of healthcare to keep me alive,

 

(b) to choose a particular physician or health care facility, and

 

(c) to receive or consent to the release of medical information and records, except as I state here: _____________________________________________________________________

__________________________________________________________________________

 

My agent shall make health care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.

 

PART 2. My Living Will

 

The following are my wishes for my future medical care to be taken on my behalf:

 

A. The following are my wishes if I have an End of life condition.

 

(i) Life-sustaining treatments

 

______ I do not want life-sustaining treatment (including CPR) started. If life-sustaining treatments are started, I want them stopped.

 

______ I want the life-sustaining treatments that my doctors think are best for me.

 

______ Other wishes

 

(ii) Artificial nutrition and hydration

 

______  I do not want artificial nutrition and hydration started if they would be the main treatments keeping me alive. If artificial nutrition and hydration are started, I want them stopped.

 

______  I want artificial nutrition and hydration even if they are the main treatments keeping me alive.

 

______  Other wishes

 

(iii) Comfort care

 

______  I want to be kept as comfortable and free of pain as possible, even if such care prolongs my dying or shortens my life.

 

______

Other wishes

 

 

B. These are my wishes if I am ever in a persistent critical condition.

 

(i) Life-sustaining treatments

 

______ I do not want life-sustaining treatment (including CPR) started. If life-sustaining treatments are started, I want them stopped.

 

______

I want the life-sustaining treatments that my doctors think are best for me.

 

______  Other wishes

 

(ii) Artificial nutrition and hydration

 

______ I do not want artificial nutrition and hydration started if they would be the main treatments keeping me alive. If artificial nutrition and hydration are started, I want them stopped.

 

______ I want artificial nutrition and hydration even if they are the main treatments keeping me alive.

 

______ Other wishes

 

(iii) Comfort care

 

______ I want to be kept as comfortable and free of pain as possible, even if such care prolongs my dying or shortens my life.

 

______ Other wishes

 

 

PART 3. Other Wishes

 

A. Organ donation

 

______ I do not wish to donate any of my organs or tissues.

 

______ I want to donate all of my organs and tissues.

 

______ I only want to donate these organs and tissues:

 

______  Other wishes

 

B. Autopsy

 

______ I do not want an autopsy.

 

______ I agree to an autopsy if my doctors wish it.

 

______ Other wishes

 

C. Other statements about my medical care

 

________________________________________________________________________

 

PART 4. Signatures

 

By my signature below, I show that I understand the purpose and the effect of this document.

 

Signature:

 

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Date:

 

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Address:

 

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B. Witnesses' signatures

 

Witness #1

 

Signature:

 

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Date:

 

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Address:

 

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Witness #2

 

Signature:

 

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Date:

 

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Address:

Description

This very important document allows you both designate someone to make health care decisions on your behalf, if you are unable to do so, and to make certain decisions yourself in advance. This is accomplished by both a Living Will and a Health Care Power of Attorney. Simply fill out the form here and print it. Once printed, you will need to initial and mark some of the choices in the Living Will and execute the document where indicated.



Instructions

Simply fill out the fields on this page with the required information. Press the "Create Form" button. If you want a blank form, leave the fields as they are and click on the 'Create Form' button. On the next page you will be able to download your completed form. The form can then be edited further or just printed. That's all there is too it. We do not collect or save any of the information you enter in these forms. The information is solely used to fill out the form you are preparing.

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