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Advance Directive Form
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Advance Directive Form

3 pages•12 fields•HIPAA-ready
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Advance Directive Form

Advance Directive Form

Page 1 of 3

Patient Full Name
Jane Martinez
Date of Birth
03/15/1985
Healthcare Proxy Name
Jane Martinez
Proxy Phone Number
(555) 867-5309
Proxy Relationship
Select relationship...
CPR Preference
Option A
Option B
Option C
Mechanical Ventilation Preference
Option A
Option B
Option C
Artificial Nutrition Preference
Option A
Option B
Option C
Organ Donation Preference
Option A
Option B
Option C
Additional Wishes
Enter details here...
Upload Existing Documents
Upload file
Patient Signature
Sign here
Submit
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The Advance Directive Form allows patients to formally document their wishes regarding medical treatment in situations where they may be unable to communicate. It covers healthcare proxy designation, living will preferences, and specific instructions for life-sustaining treatments including resuscitation, mechanical ventilation, artificial nutrition, and organ donation. This form gives patients peace of mind knowing their healthcare preferences are on record.

The form guides patients through each critical decision with clear, plain-language explanations of medical interventions. Patients can specify their preferences for different scenarios, designate a healthcare power of attorney, and indicate whether they have existing advance directive documents on file elsewhere. Upload fields allow patients to attach existing legal documents such as living wills or durable power of attorney forms.

Required by the Patient Self-Determination Act for hospitals and long-term care facilities, this form is also valuable for primary care practices, geriatric medicine offices, oncology clinics, and palliative care programs. It facilitates important conversations about end-of-life care planning and ensures patient wishes are documented and accessible to the care team.

What's included

  • Healthcare proxy designation with contact details
  • Living will preferences for life-sustaining treatments
  • CPR, ventilation, and artificial nutrition directives
  • Organ and tissue donation preferences
  • Upload field for existing legal documents
  • Witness and patient signature with date

Who uses this template

  • Hospital admission advance directive screening
  • Primary care annual wellness visit documentation
  • Geriatric and palliative care patient planning
  • Surgical pre-admission advance care planning

All form fields

12 fields across 3 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Healthcare Proxy NameText
Proxy Phone NumberPhone
Proxy RelationshipDropdown
CPR PreferenceMultiple Choice
Mechanical Ventilation PreferenceMultiple Choice
Artificial Nutrition PreferenceMultiple Choice
Organ Donation PreferenceMultiple Choice
Additional WishesLong Text
Upload Existing DocumentsFile Upload
Patient SignatureE-Signature
8 min saved per patient98% patient satisfaction3x faster than paper

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