Florida Living Will
This Living Will is made in accordance with the Florida Life-Prolonging Procedure Act. It is designed to express the desires of the person filling it out regarding their medical treatment in the event they are unable to communicate their wishes due to incapacitation.
Personal Information
Name: ____________________________________________
Date of Birth: ____________________________________
Address: _________________________________________
City: ___________________ State: FL Zip: ___________
Declaration
I, _________________________ [Insert your name], residing at _________________________ [Insert your address], being of sound mind, do hereby willfully and voluntarily declare my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and I hereby declare:
- If at any time I should have an injury, disease, or illness regarded as terminal and where the application of life-prolonging procedures would serve only to artificially delay the moment of my death:
a) I direct that such procedures be withheld or withdrawn and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfortable care.
- If I should be in a persistent vegetative state or in a condition of permanent unconsciousness, and if my attending physician and another consulting physician determine that I have no reasonable chance of recovering an intentional or cognitive function:
b) I direct that life-prolonging measures be withheld or withdrawn so that my death will not be artificially prolonged.
- I further declare that this declaration is not intended to authorize mercy killing or allow any act or omission that would violate any criminal law.
Designation of Health Care Surrogate
In the event I have been determined to be incapac is incapable of providing informed consent for medical treatment and surgical and diagnostic procedures, I wish to designate the following person as my health care surrogate:
Name of Surrogate: ___________________________________
Relationship to Me: __________________________________
Address of Surrogate: ________________________________
Phone Number of Surrogate: ___________________________
Alternate Health Care Surrogate
Should my primary surrogate be unable or unwilling to perform their duties, I designate the following person as an alternate surrogate:
Name of Alternate Surrogate: __________________________
Relationship to Me: __________________________________
Address of Alternate Surrogate: ________________________
Phone Number of Alternate Surrogate: ___________________
In testimony whereof, I have hereunto signed my name this ___ day of ___________, ______.
_________________________________
Signature
State of Florida
County of ________________
I hereby declare that the person who signed or acknowledged this document as the Principal is personally known to me and that he/she signed or acknowledged this Living Will in my presence, and that I am not a named health care surrogate or alternate health care surrogate in this document.
Witness 1: ___________________________ Date: ________
Witness 2: ___________________________ Date: ________
Signatures of Witnesses (The witnesses must not be the health care surrogate or the alternate surrogate, related by blood or marriage to the Principal, or directly financially responsible for the Principal’s medical care.)
Witness 1 Signature: _______________________________
Witness 2 Signature: _______________________________