Florida Living Will Template
This Living Will is designed to express the desires regarding medical treatment of the undersigned, in accordance with the Florida Life-Prolonging Procedure Act. It becomes effective if I am unable to make my own medical decisions.
Personal Information:
Full Name: ___________________________________________
Date of Birth: ________________________________________
Address: _____________________________________________
City: ___________________ State: FL Zip: ______________
Primary Phone: ______________________________________
Email Address: _______________________________________
Directive:
I, _________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:
- If at any time I have a terminal condition and if my attending physician has determined that there can be no recovery from such condition and my death is imminent, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong the process of dying.
- If I have been determined to be in a persistent vegetative state, I direct that life-prolonging procedures be withheld or withdrawn.
- If I have an end-stage condition, I request that all treatments other than those needed for my comfort be discontinued or withheld and that my physicians allow me to die as gently as possible.
Designation of Health Care Surrogate:
In the event I have been determined to be unable to provide informed consent for medical treatment and surgical and diagnostic procedures, I wish to designate as my surrogate for health care decisions:
Name: _______________________________________________
Relationship: ________________________________________
Primary Phone: ______________________________________
Alternate Phone: ____________________________________
If my primary surrogate is unable or unwilling to perform his or her duties, I wish to designate the following person as an alternate surrogate:
Name: _______________________________________________
Relationship: ________________________________________
Primary Phone: ______________________________________
Alternate Phone: ____________________________________
Signature:
I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.
Date: _______________________________
Signature: ___________________________
Witnesses:
The declarant has been personally known to me and I believe him/her to be of sound mind. I am not the designated surrogate or alternate surrogate named in this document.
Name: _______________________________________________
Signature: __________________________________________
Date: _______________________________
Name: _______________________________________________
Signature: __________________________________________
Date: _______________________________