Who is Health Care Agent?

• Indicate the full name of a health care agent appointed under this Living Will:

  !

  A health care agent is the trusted individual you designate in your advance directive documents like the Living Will. Their role is to speak with doctors and hospitals on your behalf when you cannot do so.

  This could be someone whom you trust, including your friends or family members. Or it could also be a doctor or medical practitioner.

• Indicate the full residential address of a health care agent:

• Indicate contact emails address and phone number of a health care agent:

• Do you want to appoint an alternative health care agent?

  • No
  • Yes

  !

  The alternative agent is the person who will step in to make medical decisions only if your primary health care agent is unable, unwilling, or legally disqualified to do so.

• Indicate the full name of an alternative health care agent:

• Indicate the full residential address of an alternative health care agent:

• Indicate contact emails address and phone number of an alternative health care agent:

• If the health care agent cannot serve, the court may appoint a guardian. State the full name of the person you wish to serve as guardian:

About the Living Will

• Select the date on which the principal signs this Living Will:

• Indicate the full name of a city, where the principal signs this Living Will:

• Indicate the full name of a county, where the principal signs this Will:

• This Living Will shall remain valid for:

  • the rest of the Principal's life
  • specific period only

• Indicate period of time (in months or years), for which this Living Will shall remain effective:

Treatment and Care

• Does the principal want to be admitted to a nursing home for long-term care?

  • No
  • Yes

• Does the Principal agree to be admitted to the community-based residential facilities for a short-term medical care?

  • Yes
  • No

• If the principal has a terminal medical condition, does the principal want food and water to be provided artificially through a tube?

  • Yes
  • No

• If the principal has a terminal medical condition, does the principal want food and water to be provided artificially through a tube?

  • Yes
  • No

• If the principal is in a terminal medical conditions, does the principal wish to delay a natural death as long as possible?

  • Yes
  • No

• If the principal has a terminal medical condition, does the principal wish to delay a natural death as long as possible?

  • Yes
  • No

• If the principal has a terminal medical condition, does the principal want life-prolonging treatment through artificial life support?

  • Yes
  • No

• If the principal has a terminal medical condition, does the principal want food and water to be provided artificially through a tube?

  • Yes
  • No

• If the principal has a terminal medical condition, does the principal want to get pain relief and comfort care?

  • Yes
  • No

• If the principal has a terminal medical condition, does the principal want to receive heart-lung resuscitation (CPR)?

  • Yes
  • No

• If the principal has a terminal medical condition, does the principal want any surgery their doctors deem necessary to prolong life?

  • Yes
  • No

• If the principal has a terminal medical condition, does the principal want to receive chemotherapy to prolong the life?

  • Yes
  • No

• Do you want to add a signature?

  • Yes
  • No

• Principal's signature:

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