Virginia Living Will
This Living Will is made in accordance with the laws of the Commonwealth of Virginia. It is designed to express your healthcare preferences in the event you are unable to communicate your wishes.
My Information:
- Name: _______________________
- Date of Birth: _______________
- Address: _____________________
- Phone Number: _______________
Declaration: I, the undersigned, designate the following individuals as my healthcare agents:
- Primary Agent Name: ______________________
- Address: _________________________________
- Phone Number: __________________________
If my primary agent is unavailable, I designate the following person:
- Alternate Agent Name: ____________________
- Address: _________________________________
- Phone Number: __________________________
Instructions: In the event of a terminal illness or condition, I express my desires regarding life-sustaining treatment as follows:
- Option 1: I wish to receive life-sustaining treatment, including artificial respiration, provided it offers a reasonable hope of recovery.
- Option 2: I do not wish to receive life-sustaining treatment if I am diagnosed with a terminal condition or if I am unable to communicate my wishes.
- Option 3: I prefer a combination of both options, depending on the circumstances.
Signature: I affirm that I am of sound mind and am making this declaration voluntarily.
- Signature: _______________________________
- Date: ___________________________________
Witnesses: This Living Will must be signed in the presence of two witnesses who are not related to me or beneficiaries of my estate.
- Witness 1 Name: ________________________
- Signature: _____________________________
- Date: __________________________________
- Witness 2 Name: ________________________
- Signature: _____________________________
- Date: __________________________________
Remember, this document should be discussed with your healthcare provider and kept in a safe but accessible location. Family members should be aware of its existence and contents. Make your wishes clear today for the peace of mind of tomorrow.