Free living will template 36
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OPTION

SURROGATE DESIGNATION AND LIVING WILL DIRECTIVE FORM
SURROGATE DESIGNATION—By initialing the lines below I specifically:
I _____________________________________________designate __________________________________________ as my health care surrogate to make health care
decisions for me in accordance with this directive when I no longer have decisional capacity. If ____________________________________ refuses or is not able to act for
me, I designate ____________________________________ as my health care surrogate. Any prior designation is revoked.
_________INITIAL

NO
ELECTION
OR

_________
Initial

OPTION

OPTION

OPTION

LIVING WILL/TREATMENT DIRECTIVES—
My wishes regarding life-prolonging treatment and artificially provided nutrition and hydration to be provided to me if I no longer have decisional capacity and have a terminal condition or if I no longer
have decisional capacity and become permanently unconscious have been indicated by initialing the appropriate lines below.