Name:
Date of Birth:
Address:
I, , being of sound mind, voluntarily make this declaration to be followed if I become unable to participate in decisions about my medical care.
If at any time I should have an incurable injury, disease, or illness certified by my physician to be a terminal condition, I direct that life-sustaining procedures that would serve only to prolong the dying process be withheld or withdrawn, and that I be permitted to die naturally.
Additional instructions (if any):
I designate the following person as my health care proxy/agent to make health care decisions on my behalf if I am unable to do so:
Name:
Relationship:
Phone: