Escolar Documentos
Profissional Documentos
Cultura Documentos
Note: Each number correlates to a particular blank or blanks on the attached sample form. 1. 2. 3. 4. Fill in the date of the declaration, ie: 23rd day of 2009. 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). 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.
Name ________4__________________________________________________ Address ________4__________________________________________________ City ________4________________________ State _4___ Zip ___4 ___ Phone ________4__________________ I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration. Additional Instructions (optional): 5 (Signed): _________6___________________________________________________ Witness __________7_____________________________ Witness ____________7___________________________ Street Address ______7_________________________ Street Address ____________7___________________ City, State & Zip _____7________________ Phone ___________7_____________________ ---- End Sample Florida Living Will Form ----