|
Bob Lin Photography services |
Living Will Form for Illinois State
ADVANCE
HEALTH CARE DIRECTIVE INSTRUCTIONS: This form lets you give specific
instructions about any aspect of your health care. Choices are provided
for you to express your wishes regarding the provision, withholding, or
withdrawal of treatment to keep you alive, as well as the provision of
pain relief. Space is provided for you to add to the choices you have
made or for you to write out any additional wishes. This form also lets
you express an intention to donate your bodily organs and tissues
following your death. Lastly, this form lets you designate a physician
to have primary responsibility for your health care. After completing this form, sign and date the form
at the end. The form must be signed by two qualified witnesses or
acknowledged before a notary public. Give a copy of the signed and
completed form to your physician, to any other health care providers you
may have, to any health care institution at which you are receiving
care, and to any health-care agents you have named. I, __________________, being of sound mind and at
least 18 years of age, declare that: (1) END-OF-LIFE
DECISIONS: I direct that my health care providers and others involved in
my care provide, withhold, or withdraw treatment in accordance with the
choice I have marked below: (Initial only one box)
•
[___] (a) Choice NOT To Prolong Life. I
do not want my life to be prolonged if (1) I have an incurable and
irreversible condition that will result in my death within a relatively
short time, (2) I become unconscious and, to a reasonable degree of
medical certainty, I will not regain consciousness, or (3) the likely
risks and burdens of treatment would outweigh the expected benefits, OR
•
[___] (b) Choice To Prolong Life. I want
my life to be prolonged as long as possible within the limits of
generally accepted health care standards. (2) RELIEF FROM PAIN:
Except as I state in the following space, I direct that treatment for
alleviation of pain or discomfort should be provided at all times even
if it hastens my death:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________. (3) OTHER WISHES: (If
you do not agree with any of the optional choices above and wish to
write your own, or if you wish to add to the instructions you have given
above, you may do so here.) I direct that:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________ (4) PRIMARY PHYSICIAN:
(OPTIONAL)
•
I designate the following physician as my
primary physician: _________________________________ (name of physician)
__________________________________________________________________ (address) (city) (state) (zip code) _________________________________ (phone) OPTIONAL: If the physician I have designated above
is not willing, able, or reasonably available to act as my primary
physician, I designate the following physician as my primary physician:
_________________________________ (name of physician)
__________________________________________________________________(address)
(city) (state) (zip code) _________________________________ (phone) (5) DONATION OF ORGANS
AT DEATH: (OPTIONAL) Upon my death: (mark applicable box)
•
[___] (a) I give any needed organs,
tissues, or parts, OR
•
[___] (b) I give the following organs,
tissues, or parts only.
•
[___] (c) My gift is for the following
purposes: (strike any of the following you do not want)
o
(1) Transplant
o
(2) Therapy
o
(3) Research
o
(4) Education In the absence of my ability to give directions
regarding the use of such life-sustaining procedures, it is my intention
that this declaration shall be honored by my family and physician(s) as
the final expression of my legal right to refuse medical or surgical
treatment, and I accept the consequences from such refusal. I understand the full import of this declaration
and I am emotionally and mentally competent to make this declaration. I execute this declaration, as my free and
voluntary act, on this ______ day of _______________, 20__, in the City
of __________________, County of __________________, State of
__________________.
______________________________________ (signature)
(INSTRUCTIONS: This advance
health care directive will not be valid for making health care decisions
unless it is either: (1) signed by two (2) qualified adult witnesses who
are personally known to you and who are present when you sign or
acknowledge your signature; or (2) acknowledged before a notary public.) I declare under penalty of perjury under the laws
of the state of (1) that the individual who signed or acknowledged this
advance health care directive is personally known to me, or that the
individual's identity was proven to me by convincing evidence, (2) that
the individual signed or acknowledged this advance directive in my
presence, (3) that the individual appears to be of sound mind and under
no duress, fraud, or undue influence, (4) that I am not a person
appointed as agent by this advance directive, and (5) that I am not the
individual’s health care provider, an employee of the individual's
health care provider, the operator of a community health care facility,
the operator of a community health care facility, the operator of a
residential care facility for the elderly, nor an employee of an
operator of a residential care facility for the elderly. I further declare under the laws of penalty of
perjury of the state of that I am neither related to the patient by
blood, marriage, or adoption, and, to the best of my knowledge, I am not
entitled to any portion of the patient's estate upon the patient's death
under a will existing when the advance directive is executed or by
operation of law. Signed at __________________ on this ____ day of
______________, 20__.
_____________________________________________________________ (name and address of first witness)
_____________________________________________________________ (name and address of second witness)
On this the ________ day of __________________,
20__, before me, the undersigned, a notary public in and for said County
and State, personally appeared _______________________________,
personally known to me (or proved to me on the basis of satisfactory
evidence) to be the person(s) whose name(s) is/are subscribed to the
within instrument and acknowledged to me that he/she/they executed the
same in his/her/their authorized capacity(ies), and that by
his/her/their signature(s) on the instrument the person(s), or entity
upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and
official seal.
____________________________________ Signature of Notary For consulting service, Contact Us |
Bob Lin Photography services
|
|