This Georgia Living Will document is intended to provide clear instructions regarding the medical treatment you wish to receive or not receive if you become unable to communicate your desires due to illness or incapacity. This document is designed in accordance with the Georgia Advance Directive for Health Care Act.
Personal Information
Full Name: _______________________________________________
Date of Birth: ___________________________________________
Address: _________________________________________________
City: _____________________ State: GA Zip: _______________
Phone Number: ____________________________________________
Social Security Number: ___________________________________
Health Care Directives
This section outlines your wishes regarding medical treatment under certain conditions.
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If I am in a terminal condition, I direct that my life not be prolonged by life-sustaining procedures, except as specified below:
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If I am in a state of permanent unconsciousness, I direct the withholding or withdrawal of all life-sustaining procedures, except as specified below:
_________________________________________________________________________________________
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In the event of a serious but non-terminal illness or injury, I wish to receive the following types of treatments and procedures (e.g., ventilator support, tube feeding):
_________________________________________________________________________________________
Additional Instructions
Here, you may specify any additional wishes or instructions you have regarding your health care treatment, including preferences for pain relief, hospice care, or any other messages to your health care providers or loved ones.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Health Care Agent
If you wish to appoint a health care agent to make decisions on your behalf if you become unable to do so, complete the information below.
Agent's Full Name: _______________________________________
Relationship to You: ______________________________________
Address: _________________________________________________
Phone Number: ____________________________________________
Alternate Agent's Full Name (if primary is unable to serve): _______________________________________
Relationship to You: ________________________________________
Address: ___________________________________________________
Phone Number: ______________________________________________
Signature
Your living will becomes legally valid once you sign it. Ensure that your signature is witnessed by two individuals or notarized.
Signature: __________________________________________ Date: _______________
Print Name: _________________________________________
Witnesses
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Witness #1 Signature: _____________________________________ Date: _______________
Print Name: _______________________________________________
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Witness #2 Signature: _____________________________________ Date: _______________
Print Name: _______________________________________________
This Georgia Living Will complies with the Georgia Advance Directive for Health Care Act. We recommend reviewing it regularly and keeping it in a safe but accessible place.