Free Florida Living Will Form

Living Will Forms, Instructions, And Services

Florida Living Will Form: Free Florida Living Will Form and Instructions. Fill out the Sample Florida Living Will and Download the Living Will Form. The following page presents a sample Florida living will form.

When reviewing or using this form, remember that state laws vary and consulting an attorney is recommended before completing this process. After filling out this living will form, consider giving a copy to an attending physician and hospital.

This ensures it is entered into medical records. Moreover, giving loved ones a copy of a living will might raise concerns, but will alleviate confusion and stress if the event ever occurs. Anyone creating a Florida living will should consider designating a health care surrogate.

Sample Living Will Form

A health care surrogate is someone designated to make care decisions in the event that a person is at the point at which this document needs to be implemented.

The designated surrogate has the authority to meet with health care providers and determine the best course of action.

Other options not presented on this Florida living will form include:

  • Many states mandate a living will be notarized, so a notary block should be present if needed.
  • The name, address, and phone number of a particular physician or physicians can be included in the form.
  • Many people also want to include a statement addressing organ donation at death.
  • Information stating the definitions of a terminal condition, end stage condition, and a persistent vegetative state.
  • Instructions on giving or withholding nutrition and hydration.

To fill out this living will form, follow these instructions:

Note: Each number correlates to a particular blank or blanks on the attached sample form.

  1. Fill in the date of the declaration, ie: 23rd day of 2009.
  2. Print or type the name of the patient.
  3. Check or place an “X” in all that apply.
  4. Print the name of the person, address, and phone number appointed to ensure the living will is carried out (unless someone is not designated).
  5. Place any additional instructions in this area regarding more specific conditions such as medical situations, medications, etc… the designated person must ensure is carried out.
  6. The signature of the individual stating they are of competent mind to implement this living will.
  7. Enter the name, address, and phone number of two witnesses. In many states, the witnesses need to be someone other than family. In addition, the person designated as the surrogate cannot be a witness.

Sample Florida Living Will Form

Florida Living Will

Declaration made this ________day of_______________ , I ________________________________ willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that, if at any time I am incapacitated and

_____ I have a terminal condition.

_____ I have an end stage condition.

_____ I am in a persistent vegetative state.

and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.

In the event that I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provisions of this declaration:

Name: _____________________________

Address: ___________________________

Phone: ____________________________

I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.

Additional Instructions (optional):_____________________________________________

(Signed): __________________________

Witness: ___________________________

Address: ___________________________

Phone: _____________________________

---- End Sample Florida Living Will Form ----

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