Texas Living Will Template
This Texas Living Will is a legal document that outlines your wishes regarding medical treatment in the event that you are unable to communicate your decisions due to illness or incapacity. It is created in accordance with the Texas Advance Directives Act.
Part 1: Personal Information
Full Name: ___________________________________________
Date of Birth: __________________
Address: _______________________________________________
City: ______________________ State: TX Zip Code: _________
Phone Number: _________________________________________
Email Address: _________________________________________
Part 2: Medical Decisions
In the event that I am unable to communicate my preferences due to a medical condition, I direct my healthcare providers to follow the instructions outlined below:
- Life-Sustaining Treatment:
I wish to receive/do not wish to receive (circle one) life-sustaining treatments if I am in a terminal condition, an irreversible condition, or in a persistent vegetative state. This may include artificial breathing, nutrition, and hydration.
- Additional Instructions:
Please provide any additional instructions or limitations you wish to place on the treatment you receive, such as pain management or specific interventions you do not wish to undergo:
________________________________________________________________________________________
________________________________________________________________________________________
Part 3: Designation of Healthcare Agent
If I am unable to make my own healthcare decisions, I designate the following individual as my healthcare agent to make medical decisions on my behalf:
Name: ___________________________________________
Relationship: ____________________________________
Phone Number: _________________________________________
Alternate Phone Number: _______________________________
Alternate Agent (if primary agent is unavailable):
Name: ___________________________________________
Relationship: ____________________________________
Phone Number: _________________________________________
Alternate Phone Number: _______________________________
Part 4: Signature
This document reflects my wishes and I sign it willingly and under no duress or undue influence. I understand that I can revoke or change this document at any time.
Date: __________________
Signature: __________________________________________
Witnesses
The above-named individual declared to us that the individual understands the contents of this document and is mentally competent to make medical decisions. As witnesses, we affix our names hereunder.
Witness 1:
Name: ___________________________________________
Date: __________________ Signature: __________________________________________
Witness 2:
Name: ___________________________________________
Date: __________________ Signature: __________________________________________
Notarization (Optional)
This section is optional and may not be required by Texas law. However, having your living will notarized may add an additional layer of validation.
State of Texas, County of ________________________
Subscribed and sworn before me on this ______ day of ___________, 20____
Notary Public: __________________________________________
Commission Expiration: _________________________________
Seal: