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 follow our instructions and 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 correlates 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.
  • Print the name of the person, address, and phone number appointed to ensure the living will is carried out (unless someone is not designated).
  • 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.
  • The signature of the individual stating they are of competent mind to implement this living will.
  • 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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