Wisconsin Living Will Form (Declaration to Physicians)Wisconsin Living Will Form (Declaration to Physicians)Wisconsin Living Will Form (Declaration to Physicians)
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DIVISION OF PUBLIC HEALTH

Scott Walker
Governor
Kitty Rhoades
Secretary

1 W EST W ILSON STREET
P O BOX 2659
MADISON W I 53701-2659

State of Wisconsin
Department of Health Services

608-266-1251
FAX: 608-267-2832
TTY: 888-701-1253
dhs.wisconsin.gov

To Whom It May Concern:
Enclosed is the Declaration to Physicians (Living Will) form you requested. This form makes it possible
for adults in Wisconsin to state their preferences for life-sustaining procedures and feeding tubes in the event the
person is in a terminal condition or persistent vegetative state.
Be sure to read both sides of the form carefully and understand it before you complete and sign it.
The withholding or withdrawal of any medication, life-sustaining procedure or feeding tube may not be
made if the attending physician advises that doing so will cause pain or reduce comfort, and the pain or
discomfort cannot be alleviated through pain relief measures.
Two witnesses are required. Witnesses must be at least 18 years of a