Tennessee Living Will Template
This document is a Living Will template specific to the state of Tennessee, adhering to the requirements set forth in the Tennessee Right to Natural Death Act. By completing this form, you are making known your wishes regarding medical treatment in the event you are unable to communicate those wishes yourself.
Please provide the following information:
- Full Name: ____________________________
- Date of Birth: ____________________________
- Address: ____________________________
- City, State, ZIP Code: ____________________________
- Primary Phone Number: ____________________________
In accordance with the Tennessee Right to Natural Death Act, I, ______________________ (your full name), a resident of ______________________ (city, state), born on ______________________ (date of birth), hereby declare my wishes as follows:
- I wish to designate the following individual as my health care agent to make any and all health care decisions for me in accordance with this document, especially in the event that I become unable to communicate my healthcare wishes myself.
- Health Care Agent's Full Name: ____________________________
- Relationship to Me: ____________________________
- Primary Phone Number: ____________________________
- Alternate Phone Number: ____________________________
- I instruct that all treatments designed to prolong my life be withheld or discontinued if the following conditions are met:
- I am in a terminal condition and the use of life-sustaining procedures would only serve to artificially prolong the dying process; or
- I am in a persistent vegetative state with no reasonable expectation of recovery.
- I desire that my pain be kept to a minimum, even if this means that my life is shortened.
- I wish to make the following anatomical gifts (if any):
- Organ Donation: ____________________________
- Tissue Donation: ____________________________
- Body Donation for Scientific Study: ____________________________
- Other Wishes or Instructions: ____________________________
This document is signed voluntarily as an expression of my legally binding wishes regarding my health care under Tennessee law.
Date: ____________________
Signature: ____________________
Witness Information:
I, ____________________ (name of witness), declare that ____________________ (name of declarant) signed this document in my presence and appears to be of sound mind and free from duress. I am not related by blood or marriage to the declarant and am not entitled to any part of the declarant’s estate upon death.
Date: ____________________
Witness Signature: ____________________
Witness Address: ____________________
Second Witness Information:
I, ____________________ (name of second witness), declare the same as the above witness regarding the declarant’s signing of this document.
Date: ____________________
Second Witness Signature: ____________________
Second Witness Address: ____________________