Living Will and Testament
This form allows you to declare your medical care preferences and directives.
Personal Information
Full Name
Date of Birth
Address
Healthcare Preferences
Medical Treatment Preferences
Other Directives or Instructions
Healthcare Proxy (if any)
Name of Healthcare Proxy
Contact Information
Signature
Date
Signature
Witnesses
Witness 1 Name
Witness 1 Signature
Date
Witness 2 Name
Witness 2 Signature
Date