Texas Living Will
This Living Will is created in accordance with Texas law regarding advance directives. It outlines your wishes regarding medical treatment in case you are unable to communicate your preferences.
Personal Information:
- Name: ________________________
- Date of Birth: ________________________
- Address: ________________________
- City, State, Zip Code: ________________________
- Phone Number: ________________________
Declaration:
I, _____________, being of sound mind, voluntarily make this statement as a directive to be followed if I become unable to communicate my healthcare decisions. I understand that this directive will remain effective until revoked.
Healthcare Preferences:
- If I am in a terminal condition or a state of permanent unconsciousness, I wish to:
- Receive life-sustaining treatment (Yes / No): ____________
- Receive pain relief medication (Yes / No): ____________
- If I have a condition from which I cannot recover, I wish to:
- Be allowed to die naturally (Yes / No): ____________
- Receive artificial nutrition and hydration (Yes / No): ____________
Appointment of Medical Power of Attorney (optional):
I appoint the following person to make healthcare decisions on my behalf if I am unable to do so:
- Name of Agent: ________________________
- Relationship: ________________________
- Phone Number: ________________________
Signature:
Signature: ________________________
Date: ________________________
Witnesses:
This document must be signed in the presence of two witnesses or a notary public. Witnesses must be at least 18 years old and cannot be related to me or be my healthcare provider.
- Witness 1: ________________________ Date: ________________________
- Witness 2: ________________________ Date: ________________________