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Living Will Declaration

Complete the form field below to generate a Living Will Declaration that you can print and bring with you to your estate planning attorney. Click here for an example.

In order for the letter to be properly generated, all fields on this form must be completed. No information is gathered or used by us for any purpose whatsoever. It's just used to generate the printable letter.

Declarant:
(Your name)
Street Addresss:
(Your street address)
City:
County/Parish:
(Please indicate your county or parish of residence)
*State or Province:
(Select a state for U.S. clients or a Canadian province)
*Zip/Postal Code:
*Country:
Use the optional space below to indicate that medical care you would like to receive if you are pregnant and near death or in a permanent vegetative state.
Pregnancy Clause:
(Press <ENTER> to start a new line.)
The following are further instructions pertaining to health care you either wish to have or not to have should you be near death or in a permanent vegetative state and unable to communicate your wishes to medical staff. You will need to either select "Do" or "Do Not" depending on your wishes for medical care.
  • I want to be revived or resuscitated.
  • I want electrocardioversion.
  • I want mechanical respiration.
  • I want antibiotics.
  • I want kidney dialysis.
  • I want tube feeding or any other artificial or invasive form of nutrition (food).
  • I want any artificial or invasive form of hydration (water).
  • I want blood or blood products.
  • I want any form of life sustaining surgery or invasive diagnostic tests.
  • I want to allow physicians to try new medical discoveries on me.
  • I want to make an anatomical gift of any part of my body, subject to the following limitations:

    (Use this optional text box to indicate limitations to your anatomical gifts, if any. Press <ENTER> to start a new line.)
In the following, please select the option that indicates where you want to spend your last days. You can choose to spend your last days at home, be hospitalized or indicate that you have no preference.
Home or Hospital:

This form is not a substitute for legal advise, and it is suggested that an attorney be consulted.