This California Living Will document is prepared in accordance with the California Natural Death Act. It is designed to express the wishes of the individual regarding their medical treatment in the event they are unable to communicate their decisions due to incapacity.
Personal Information
- Full Name: ____________
- Date of Birth: ____________
- Address: ____________
- City: ____________
- State: California
- Zip Code: ____________
- Phone Number: ____________
- Email Address: ____________
Designation of Health Care Agent
I, ____________ (name), appoint the following person as my agent to make health care decisions for me:
- Agent's Full Name: ____________
- Relationship to me: ____________
- Agent's Address: ____________
- Agent's Phone Number: ____________
- Alternative Agent's Full Name: ____________
- Relationship to me (Alternative Agent): ____________
- Alternative Agent's Address: ____________
- Alternative Agent's Phone Number: ____________
Instructions for Health Care
In the event that I am unable to make my own health care decisions, I direct that my health care providers and my agent follow my instructions as indicated below:
- I do/do not (circle one) want my life to be prolonged by life-sustaining treatments if I am in a terminal condition or in a permanent unconscious state. Specific instructions: ____________
- I do/do not (circle one) want to receive nutrition and hydration provided by medical means if I am unable to take food or water by mouth. Specific instructions: ____________
- Other instructions, including preferences about pain relief, hospital care, palliative care, and any other specific treatments I want or do not want: ____________
Signature and Witnesses
This Living Will is effective as of the date signed. My signature affirms that I am of sound mind, understand the contents of this document, and have made these decisions of my own free will.
Principal's Signature: ____________ Date: ____________
Witnesses (Must be 18 years of age or older and not related to the principal by blood, marriage, or adoption, and not entitled to any portion of the principal's estate.)
- Witness 1 Signature: ____________ Date: ____________
- Witness 1 Printed Name: ____________
- Witness 2 Signature: ____________ Date: ____________
- Witness 2 Printed Name: ____________