To fill out this living will form, follow these instructions:

Note: Each number correlates to a particular blank or blanks on the attached sample form. 1. 2. 3. 4. Fill in the date of the declaration, ie: 23rd day of 2009. Print or type the name of the patient. Check or place an X in all that apply. Print the name of the person, address, and phone number appointed to ensure the living will is carried out (unless someone is not designated). 5. Place any additional instructions in this area regarding more specific conditions such as medical situations, medications, etc the designated person must ensure is carried out. 6. The signature of the individual stating they are of competent mind to implement this living will. 7. Enter the name, address, and phone number of two witnesses. In many states, the witnesses need to be someone other than family. In addition, the person designated as the surrogate cannot be a witness.

Sample Florida Living Will Form

Florida Living Will Declaration made this ____1____day of________1_______ , I _________________2_______________ willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that, if at any time I am incapacitated and __3___ I have a terminal condition. or __3___ I have an end stage condition. or __3___ I am in a persistent vegetative state. and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that lifeprolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the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 comfort care or to alleviate pain. It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal. In the event that I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provisions of this declaration:

Name ________4__________________________________________________ Address ________4__________________________________________________ City ________4________________________ State _4___ Zip ___4 ___ Phone ________4__________________ I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration. Additional Instructions (optional): 5 (Signed): _________6___________________________________________________ Witness __________7_____________________________ Witness ____________7___________________________ Street Address ______7_________________________ Street Address ____________7___________________ City, State & Zip _____7________________ Phone ___________7_____________________ ---- End Sample Florida Living Will Form ----