This Living Will is designed to reflect the wishes of the individual regarding medical treatment in the event they are unable to communicate their decisions due to illness or incapacity. This document is created in accordance with the Oklahoma Advance Directive Act.
Part 1: Information of the Principal
Full Name: ________________________________________
Date of Birth: _____________________________________
Address: __________________________________________
City: ______________________ State: OK Zip: _________
Part 2: Treatment Preferences
This section outlines your wishes regarding life-sustaining treatment and other specific medical interventions. Please indicate your preferences clearly.
- Life-sustaining treatment:
____ I wish to receive all life-sustaining treatments, including CPR, should I be in a terminal condition or an end-stage condition.
____ I do not wish to receive life-sustaining treatments if I am in a terminal condition or an end-stage condition and the treatments would only prolong the process of dying.
- Artificial Nutrition and Hydration (ANH):
____ I wish to receive artificial nutrition and hydration, regardless of my medical condition.
____ I do not wish to receive artificial nutrition and hydration if I am in a terminal condition or an end-stage condition.
- Additional Instructions (Optional):
Please provide any specific instructions or limitations regarding your health care treatment that you wish to be followed:
__________________________________________________________________________
__________________________________________________________________________
Part 3: Health Care Proxy
If you are unable to make health care decisions for yourself, you can appoint a health care proxy to make decisions on your behalf. Please provide the information of your appointed health care proxy.
Health Care Proxy's Full Name: _______________________________
Relationship to Principal: ___________________________________
Primary Phone Number: ______________________________________
Alternate Phone Number: ___________________________________
Part 4: Signature
My signature below indicates that I fully understand the nature of this Living Will and I am emotionally and mentally competent to make this advanced directive.
Principal's Signature: ___________________________ Date: ___________
Witness's Signature: _____________________________ Date: ___________
Printed Name of Witness: ___________________________________
Part 5: Notarization (Optional)
This section to be completed by a Notary Public if required or desired.
State of Oklahoma, County of _________________________________
On _______________ (date), before me, __________________________________ (notary's name), personally appeared ________________________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that they executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
Notary's Signature: _______________________________
Notary's Printed Name: ____________________________
Commission Expires: ______________________________