Florida Living Will

Transcript

1 S INSTRU CTION NG WILL FLORIDA LIVI ________________________________ PRINT THE DATE Declaration made this _________ _____ day of _____________, _______ (day) onth) (year) (m PRINT YOUR _______________, _________ I, _________________________ ______ NAME willfully and voluntarily make known my desire that my dying not be umstances set forth below, and I do artificially prolonged under the circ lare that: hereby dec PLEASE INITIAL EACH THAT me I am incapacitated and If at any ti APPLIES __________I have a terminal condition, or __________I have an end-stage condition, or in a per sistent vegetative state am __________I an and another consulting ph and if my attending or treating physici ysician have determined that ther e is no reasonable medi cal probability of my recovery from such condition, I direct that life-prolonging procedures be ation of such procedures would hen the applic withheld or withdrawn w he process of dying, and that I be serve only to prolong artificially t he administration of medication or the permitted to die naturally with only t performance of any medical procedure deemed necessary to provide me with comfort care or to allev iate pain. larat It is my intention that this dec ion be honored by my family and legal right to refuse medical o r physician as the final expression of my surgical treatment and to accept t he conseq uences for such refusal. ned to be unable to provide express In the event that I have been determi and informed consent regarding t he withholding, withdrawal, or e-prolonging procedures, I wis h to designate, as my continuation of lif claration: provisions of this de surrogate to carry out the PRINT THE ____________ ______________ Name: ___________________________ OME NAME, H ADDRESS AND ________________________ ___________________ Address: ________ TELEPHONE R OF NUM BE ________________________ _________________Z ip Code:__________ YOUR SURROGATE ______________ ____________ __________________________ Phone: © 2000 HIP NERS PART G, FOR CA RIN INC. Produ for t he Fl orida Develo pmental Disab ilities Co un cil ced By Pr og ram Desig n, In c. 5 /03

2 FLORIDA LI V ING WILL ( CONTINUE D ) I wish to designate the following person as my alternate surrogate, to carry out the provisions of this declarat ion should my surrogate be unwilling or unable to act on my behalf. PRINT NAME, HOME Name: ____________________ __________________ _______________ ADDRESS AND TELEPHONE ________________________ ___________________ Address: ________ NUM BE R OF YOUR ATE RN ALTE _____________ ________________________ Zip Code: ____________ SURROGATE Phone: ____________________ ___________ AD D PERSONAL nstructions (optional): Additional I S CTION INSTRU ) (IF ANY this declaration, and and I am emotionally I understand the full import of mentally competent to make this declaration. SIGN THE CUME NT DO ________ Signed: ____________________ ________________________ WITNESSING DURE PROCE Witness 1:: TWO WITNESSES __________________ Signed: ___________ _________________ MUST SIGN T AN D PRIN Address: __________ __________________ _________________ THEIR ADDRESSES Witness 2: __________________ ___________ Signed: _________________ _________________ Address: __________ __________________ © 2000 HIP PART NERS Courtesy of 6/00 Partnership for Caring, Inc G, RIN FOR CA 1620 Eye St reet, NW Suite 202 Washington, DC 20006 800-989-9455 INC. ced ilities Co he Fl orida Develo pmental Disab Produ un cil for t og ram Desig n, In c. 5 /03 By Pr

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