Florida Living Will Template
This document serves as a Living Will, conforming to the Florida Living Will statutes (Chapter 765, Florida Statutes), designed to express the desires of the undersigned regarding health care decisions in the event the individual is unable to communicate wishes due to a terminal condition, end-stage condition, or persistent vegetative state.
Personal Information
Name: ___________________________
Address: ___________________________
Date of Birth: ___________________________
Social Security Number: ___________________________
Declaration
I, ___________________________ (the "Declarant"), residing at ___________________________, being of sound mind and not under or subject to duress, fraud, or undue influence, do hereby declare my directive as follows:
Directions for Health Care
In the event that I, ___________________________, become incapacitated and am determined by a physician to be in a terminal condition, end-stage condition, or in a persistent vegetative state, I direct that all measures be withheld or withdrawn that prolong the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfortable care, including the relief of pain.
In such circumstances, I further direct the following specific directives to be followed (please mark your preferences):
- ___ Do not administer life-prolonging treatments, except as needed for comfort care.
- ___ I wish to receive the following treatments or interventions: ___________________________
- ___ Other directions or preferences: ___________________________
Designation of Health Care Surrogate
In the event that I am unable to make my own health care decisions, I designate the following individual as my Health Care Surrogate to make health care decisions for me as authorized in this document:
Name of Health Care Surrogate: ___________________________
Address of Health Care Surrogate: ___________________________
Phone Number of Health Care Surrogate: ___________________________
In the event my primary surrogate is unwilling or unable to perform their duties, I designate the following individual as my alternate Health Care Surrogate:
Name of Alternate Health Care Surrogate: ___________________________
Address of Alternate Health Care Surrogate: ___________________________
Phone Number of Alternate Health Care Surrogate: ___________________________
Signature and Witness Requirements
In witness whereof, I have executed this Living Will on the date indicated below. My signature on this document is intended to signify that I understand the nature and purpose of this document and the options I have selected. This document will not be valid unless it is signed by two competent adult witnesses, who are present when I sign or acknowledge the sign. Witnesses cannot be the named Health Care Surrogate, a spouse, or a blood relative.
Date: ___________________________
Signature of Declarant: ___________________________
Printed Name of Declarant: ___________________________
Witness 1 Signature: ___________________________
Printed Name of Witness 1: ___________________________
Witness 2 Signature: ___________________________
Printed Name of Witness 2: ___________________________