Georgia Living Will Declaration
This Living Will is designed in accordance with the Georgia Advance Directive for Health Care Act. It provides a legal way for individuals, while competent, to outline their preferences and instructions for medical treatment should they become unable to communicate these wishes due to illness or incapacity.
Personal Information
Full Name: _______________________________
Date of Birth: ____________________________
Address: __________________________________
City: _____________________________________
State: Georgia
Zip Code: _________________________________
Declaration Statement
I, ______________ [Full Name], born on ______________ [Date of Birth], residing at _________________________________________________ [Address], being of sound mind, do hereby voluntarily make known my desire that my dying should not be artificially prolonged under the circumstances set forth below, and I declare:
- If I am in a terminal condition, I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below:
- _____ To withhold or withdraw treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain.
- _____ To receive treatment that may prolong my life, including, but not limited to, surgery, blood transfusions, and the administration of drugs.
- If I am in a state of permanent unconsciousness, I direct the following concerning the provision, withholding, or withdrawal of life-sustaining procedures:
- _____ I do not want my life to be prolonged by life-sustaining procedures, though if I am suffering, I want to receive treatment necessary to relieve pain.
- _____ I want my life to be prolonged to the greatest extent possible, using all available life-sustaining treatments.
- Other directions: ___________________________________________________________________________________________________________________________________________________________.
Agent Designation (Optional)
I designate the following individual as my agent to make health care decisions for me if I become unable to make these decisions for myself:
Name: _______________________________
Relationship to me: ____________________
Address: ______________________________
Phone Number: _________________________
Alternate Phone Number: ________________
Signatures
This declaration is made this _____ day of ______________, 20__.
__________________________________
Signature of Declarant
State of Georgia
County of ________________
On this day, before me personally appeared ____________________________, to me known to be the person described in and who executed the foregoing declaration, and acknowledged that he/she executed the same as his/her free act and deed.
__________________________________
Notary Public
My commission expires: ______________