Florida Living Will Form
How to Complete & Use a Healthcare Directive
Use our free Florida Living Will form with these simple to follow instructions. Also known as a Florida Healthcare Directive, just copy, paste, print.
This form is specifically worded to follow a commonly accepted format for Florida.
When using this form for multiple states, remember that state laws vary and consulting an attorney is recommended.
After completing the living will form, consider giving a copy to an attending physician and hospital staff.
This ensures it is entered into your medical records.
Also, you should give trusted loved ones a copy of your Florida living will healthcare directive.
Anyone creating a living will should carefully consider who they choose to be their designated health care surrogate.
Who is the Healthcare Surrogate?
A health care surrogate is someone designated to make health care decisions
in the event that a person can no longer competently make informed decisions.
The designated surrogate has the authority to meet with health care providers and determine the best course of action.
Other options that can be included in your Florida living will form:
- Tip for Snowbirds: Many states mandate that a living will is notarized, so a notary block should be added if you are using this form in multiple states.
- The name, address, and phone number of more than one physician 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.
The sample living will form below can be copied and pasted into your favorite word processor and edited to include any or all of these provisions.
How to Complete the Living Will Form
To fill out the Florida Living Will form, just follow these instructions:
Note: Each bullet corresponds to a particular blank or blanks on the sample form below.
- Fill in the date of the declaration, ie: 23rd day of June, 2014.
- Print or type the name of the patient.
- Check or place an “X” in all that apply.
the name of the person, address, and phone number appointed to ensure
the living will is carried out (unless someone is not designated).
any additional instructions in this area regarding more specific
conditions such as medical situations, medications, etc… the designated
person must ensure is carried out.
- The signature of the individual stating they are of competent mind to implement this living will.
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
---- Sample 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
I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
Additional Instructions (optional):_____________________________________________________
---- End Sample Florida Living Will Form ----
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Article by Kenneth Diaz, Florida-Court-Forms.net © 2015
Page last updated 02/19/2015
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