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Practice name: ______________________________
Advance Directive Form
Advance Directive / Living Will An advance directive is a legal document that communicates your healthcare wishes in the event that you are unable to make decisions for yourself. This document allows you to specify your preferences for life-sustaining treatments and to designate a healthcare proxy who can make medical decisions on your behalf. This directive will take effect only if you become incapacitated and are unable to communicate your wishes to your healthcare providers. You may revoke or modify this directive at any time while you are competent to do so. We strongly recommend discussing your wishes with your healthcare proxy, family members, and healthcare providers to ensure your preferences are clearly understood. Important: This document should be reviewed periodically and updated as your wishes change. Copies should be provided to your healthcare proxy, your physician, and any healthcare facility where you receive care.
Full Name *
Date of Birth *
____ / ____ / ________
Life-Sustaining Treatment Preferences *
- Full treatment — I want all available medical treatments used to sustain my life
- Limited treatment — I want treatment only if there is a reasonable chance of recovery
- Comfort care only — I want only measures to keep me comfortable and manage pain
Cardiopulmonary Resuscitation (CPR) Preference *
- Attempt CPR
- Do Not Resuscitate (DNR)
Mechanical Ventilation Preference *
- Use ventilator as needed
- Do not use a ventilator
- Trial period only — use ventilator for a limited time, then reassess
Artificial Nutrition and Hydration Preference *
- Provide artificial nutrition and hydration
- Do not provide artificial nutrition or hydration
- Trial period only — provide for a limited time, then reassess
Healthcare Proxy Name *
Healthcare Proxy Phone Number *
Healthcare Proxy Relationship *
Additional Wishes or Instructions
Full Name (Patient) *
Date *
____ / ____ / ________
Advance Directive Form template from formisoft.com. formisoft.com/intake-templates/advance-directive