Wyoming Living Will Template
This Living Will document is prepared in accordance with the Wyoming Health Care Decisions Act. It is designed to express the desires of the individual regarding medical treatment in the event they are unable to communicate their wishes personally.
Personal Information
Full Name: ___________________________________________
Date of Birth: ________________________________________
Address: ______________________________________________
City: ___________________ State: WY Zip: _______________
Health Care Wishes
This section outlines your health care preferences in circumstances where you are unable to make decisions for yourself.
- Life-Sustaining Treatment:
- If I am in a terminal condition, I do / do not (circle one) want my life to be prolonged by life-sustaining treatments. If I do not want life-sustaining treatments, I wish the following to be administered or withheld:
- Artificial Nutrition and Hydration:
- I do / do not (circle one) want artificial nutrition and hydration if the only purpose it serves is to prolong the dying process.
- Pain Relief:
- I wish to receive medication to relieve pain or discomfort, even if it may hasten my death.
Designation of Health Care Agent
If you wish to appoint a health care agent to make decisions on your behalf should you be unable to do so, please provide their information below.
Agent's Full Name: ___________________________________
Relationship: ________________________________________
Primary Phone: _______________________________________
Alternate Phone: _____________________________________
Alternate Agent
If the primary agent is unable or unwilling to serve, an alternate agent can act in their stead.
Alternate Agent's Full Name: ___________________________
Relationship: _________________________________________
Primary Phone: ________________________________________
Alternate Phone: ______________________________________
Signature
This document is not valid unless signed by the declarant or a representative at the direction of the declarant. This must be done in the presence of two witnesses.
_______________________________________ _______________
Signature of Declarant or Representative Date
Witnesses:
1. ___________________________________________________________________
Signature of Witness #1 Date
2. ___________________________________________________________________
Signature of Witness #2 Date
This Living Will becomes effective only when the person who created it is unable to make their own health care decisions as certified by two physicians.
Revocation
This Living Will can be revoked at any time by the declarant in any manner without regard to the physical or mental condition of the declarant. Such revocation becomes effective upon communication to the attending physician or other health care provider by the declarator or a witness to the revocation.
Prepared this ____ day of ______________, 20____.