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Enter the full legal name of this person as it would appear on a legal document.
Enter the full legal name of this person as it would appear on a legal document.
An Advance Healthcare Directive (also called a Combined Healthcare Directive or Five Wishes Document) is the comprehensive legal document that combines a Living Will (your instructions for end-of-life care) with a Healthcare Power of Attorney (your appointment of a healthcare agent to make medical decisions if you are incapacitated). All 50 states recognize advance directives in some form, though the specific requirements vary by state. This is the most important document any adult can have — every adult over 18 should have one. Without it, family members may disagree about care decisions, and hospitals default to aggressive life-sustaining treatment. Fill out this free advance healthcare directive template online, e-sign it digitally, and download a legally valid PDF. no account or lawyer needed. Sections: Your Information, Care Wishes.
I, ______________, born ______________, residing at ______________, being of sound mind, make this Advance Healthcare Directive to state my wishes about medical care and to appoint a Healthcare Agent. I understand the importance of this document and sign it voluntarily on ______________.
I appoint the following person as my Healthcare Agent — the person authorized to make all healthcare decisions for me if I become unable to make or communicate decisions for myself: Agent: ______________ Relationship: ______________ Phone: ______________ If my primary agent is unavailable or unable to serve, I appoint the following Alternate Agent: ______________
My Healthcare Agent shall have full authority to: (a) consent to or refuse any medical treatment, procedure, or test; (b) authorize or withhold life-sustaining treatment; (c) consent to pain management including medications that may hasten death; (d) choose or change healthcare providers and facilities; (e) authorize transfer to hospice; and (f) access all of my medical records. My Agent shall follow my wishes as expressed in this Directive.
If I have a terminal condition and death is expected within 6 months even with treatment: ______________.
If I am permanently unconscious or in a persistent vegetative state with no reasonable possibility of recovery: ______________.
Regarding a feeding tube or intravenous feeding: ______________.
Regarding cardiopulmonary resuscitation (CPR): ______________.
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No additional instructions. I trust my Healthcare Agent to make decisions consistent with the spirit of this Directive and my values.
I have discussed my wishes with my Healthcare Agent and I am satisfied that this Directive accurately reflects my intentions. I understand that I may revoke this Directive at any time by destroying it, writing "REVOKED" across it, or by executing a new Directive.
Declarant Signature: ______________________________ ______________ Date: ____________________
WITNESS ATTESTATION We, the undersigned, certify that the Declarant signed this Directive willingly, in our presence, and appears to be of sound mind. Neither witness is the Declarant's Healthcare Agent, related to the Declarant by blood or marriage, entitled to any portion of the Declarant's estate, or the Declarant's attending physician. Witness 1: _________________________ Date: _________ Printed Name: _________________________ Witness 2: _________________________ Date: _________ Printed Name: _________________________
NOTARY ACKNOWLEDGMENT (recommended) State of ______________ — County of ____________________ Before me personally appeared ______________, known to me, who acknowledged signing this Advance Healthcare Directive voluntarily. Notary Public: _________________________ My Commission Expires: _________________ [SEAL]