Please enter all of the information requested. Some of it goes into the document we will prepare, and your mailing address is where we will send the document once it has been prepared and finalized.

 

 

 

Below, enter the person you select as your health care agent. Your health care agent is the person who, in accordance with your living will, will make health care decisions for you when you are unable to communicate the decisions yourself.

 

 

 

In the event that your primary designated health care agent is unable or unwilling to serve, you need to designate a back-up agent.

 

 

 

In the event that your primary designated health care agent AND your back-up health care agent are unable or unwilling to serve, you need to designate a second back-up agent.

 

 

 

Below, you will decide what powers your health care agent will have after your death.

 

An autopsy is an inspection and dissection of your body after death, typically to determine the cause of death. Your answer below is for whether you want your health care agent to have the power to order an autopsy if he or she deems it necessary. Note that state law may override your decision in certain circumstances.

 

My agent WILL have the power to order an autopsy.
My agent WILL NOT have the power to order an autopsy.

 

If you haven`t become an organ donor previously, this will give your health care agent the power to donate your organs.

 

My health care agent WILL have the power to donate my organs.
My health care agent WILL NOT have the power to donate my organs.

 

The question below allows your health care agent to donate your body to a medical studies program (such as for the training of medical school students) if he or she deems fit.

 

My agent WILL have the power to donate my body to science.
My agent WILL NOT have the power to donate my body to science.

 

I wish to be buried.
I wish to be cremated.

 

A `final disposition` means what happens to your body, i.e. where it is buried, when it is cremated, etc.

 

My agent WILL make final disposition of my body.
My agent WILL NOT make final disposition of my body.

 

If you selected `WILL NOT` as to the final disposition of your body, you need to select someone who will be responsible for your burial/cremation arrangements. List this person below. If you selected `WILL`, you do not need to enter another person`s information below.

 

 

 

You will make selections as to lifesaving measures in the next section. However, now you need to decide when the lifesaving measures (or lack of) will apply.

A Terminal Condition means that you have an incurable or irreversible condition that will result in your death in a relatively short period of time.

A State of Permanent Unconsciousness means that you are in an incurable or irreversible condition in which you are not aware of yourself or your environment and you show no behavioral response to your environment.

Note: Whether you are in one of these two conditions will be determined in writing after physical examination by your attending physician and a second physician in accordance with currently accepted medical standards.

 

My living will WILL be effective if I am in a terminal condition.
My living will WILL NOT be effective if I am in a terminal condition.

 

My living will WILL be effective if I am permanently unconscious.
My living will WILL NOT be effective if I am permanently unconscious.

 

 

Try to extend my life as long as possible, using every medical means.
Allow my natural death to occur; only give me pain medicine.
I don`t want medications, machines, procedures, except as noted below.

 

I WANT nutrition by tube.
I DO NOT WANT nutrition by tube.

 

I WANT fluids by other means.
I DO NOT WANT fluids by other means.

 

I WANT to be on a ventilator.
I DO NOT WANT to be on a ventilator.

 

I WANT cardiopulmonary resuscitation (CPR).
I DO NOT WANT cardiopulmonary resuscitation (CPR).

 

I want to be kept alive until the fetus is viable and can be removed.
I want my wishes above to be carried out, terminating the fetus.
I am a man, this is not applicable to me.

 

If you have any other specific medical requests, you may enter them below.

NOTE: Most people do not list additional requests, and this is optional. It is impossible to cover every medical situation and possibility in a living will.

 

 

 

A guardian is a person, usually appointed by a court, who is entrusted by law with the care of person, property, or both, of another who is legally incapable of managing his or her own affairs.

 

I NOMINATE my health care agent as my guardian.
I DO NOT NOMINATE my health care agent as my guardian.

 

If you DO NOT NOMINATE your health care agent as your guardian, list the person below whom you wish to be your guardian.

 

 

If you have any other questions, comments, etc., enter them below.

 

 

Visa
Mastercard
Discover
American Express
Cash
Check
Money Order
Gift Certificate (Such as dealmobs, groupon, etc.)

 

$250 (one living will)
$350 (two living wills)

 

 

If you are paying by cash, check, or money order, we will contact you to make payment arrangements.