Florida Living Will Template
This Living Will is designed to comply with the laws of the State of Florida. It outlines your wishes regarding medical treatment in the event you become unable to communicate.
Principal’s Information:
Name: ________________________________________
Date of Birth: __________________________________
Address: ______________________________________
City, State, Zip: _____________________________
Declaration:
I, the undersigned, being of sound mind, willfully and voluntarily make this declaration on this ____ day of ______________, 20__.
In the event that I am diagnosed with a terminal illness or an end-stage condition, and I am no longer capable of making my own healthcare decisions, I express my wishes as follows:
- I do not wish to receive life-prolonging procedures if my attending physician determines that these procedures would only prolong the process of dying.
- I wish to receive comfort care and pain management as deemed necessary, even if it may hasten my death.
- In instances where I may be in a persistent vegetative state or suffering from an irreversible condition, I prefer to avoid any extraordinary measures to prolong my life.
Designation of Healthcare Surrogate:
If needed, I designate the following person as my healthcare surrogate:
Name of Surrogate: _____________________________
Address: ______________________________________
Phone Number: ________________________________
Signature:
_______________________________________________
(Signature of Principal)
Witnesses:
This Living Will must be witnessed by two individuals who are not related to the Principal, nor benefit from the Principal's estate.
Witness 1: ____________________________________
Signature: _____________________________________
Date: _________________________________________
Witness 2: ____________________________________
Signature: _____________________________________
Date: _________________________________________
Notary Public: (Optional)
State of Florida
County of ____________________________________
Subscribed and sworn before me this ____ day of ______________, 20__.
_______________________________________________
Notary Public Signature