Pennsylvania Living Will
This Living Will is executed in accordance with the laws of the Commonwealth of Pennsylvania.
Please provide the following information:
- Your Full Name: ____________________________
- Your Address: ____________________________
- Your Phone Number: ____________________________
- Your Date of Birth: ____________________________
This document reflects my wishes regarding medical treatment in the event that I become unable to communicate my preferences.
I wish to address the following conditions:
- If I am diagnosed with a terminal illness, I do not wish for life-sustaining treatment to be administered.
- If I am in a persistent vegetative state, I do not wish to receive life-sustaining treatment.
- I may specify preferences regarding pain relief and comfort care, as follows:
Additional Preferences:
______________________________________________________________________
______________________________________________________________________
It is my strong desire that:
- Name of Healthcare Agent: ____________________________
- Agent's Phone Number: ____________________________
- Agent's Address: ____________________________
This individual is authorized to make medical decisions on my behalf if I am unable to do so.
I understand that I may revoke this Living Will at any time by notifying my healthcare providers. This notice may be verbal or in writing.
Signed this _____ day of ____________, 20___.
Signature: _______________________________
Witness 1 Name: _______________________________
Witness 1 Signature: _______________________________
Witness 2 Name: _______________________________
Witness 2 Signature: _______________________________