Florida Living Will Template
This document serves as a Living Will, prepared in accordance with the Florida Life-Prolonging Procedure Act, intending to guide healthcare providers and loved ones regarding the principal's preferences for life-prolonging treatments and procedures in situations where the principal cannot make their own health care decisions.
Principal's Information
Full Name: ___________________________
Date of Birth: ________________________
Address: ______________________________
City: __________________________________
State: Florida
Zip Code: _____________________________
Phone Number: _________________________
Declaration
I, ________________________ [insert full name], being of sound mind and not under duress, fraud, or undue influence, do hereby declare my desires concerning the provision, withholding, or withdrawal of life-prolonging procedures. Should I, at any time, be incapable of making my own health care decisions due to a terminal condition, an end-stage condition, or being in a persistent vegetative state, I direct the following actions be taken regarding my care:
Directions for Health Care:
- I desire that all life-prolonging procedures be ___________ [withheld/withdrawn/provided], except as I state otherwise in this document.
- In the case of a terminal condition, I wish for ______________________________________________________________________.
- In the case of an end-stage condition, my desires are _________________________________________________________________.
- If I am in a persistent vegetative state, I direct that __________________________________________________________________.
Designation of Health Care Surrogate
In the event I have been determined to be unable to provide informed consent for medical treatment or surgical and diagnostic procedures, I designate the following person as my surrogate for health care decisions:
Name: ___________________________
Relationship to Me: _______________
Primary Phone Number: ______________
Alternative Phone Number: ____________
Additional Instructions
Any additional instructions regarding my desires for medical treatment, including but not limited to preferences concerning artificial nutrition and hydration, are as follows:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Declaration
This Florida Living Will expresses my legal right to refuse treatment and is executed in accordance with Florida state law. I understand the full import of this declaration and I am emotionally and mentally competent to make this Living Will.
Signature
Signature: ___________________________
Date: ____________________________
Witness: ____________________________
Date: ____________________________
Second Witness: ____________________________
Date: ____________________________
Witnesses are required by Florida law to confirm that the principal appeared to be of sound mind and free of duress at the time of signing the Living Will. Witnesses cannot be the principal's spouse or blood relative.