Arkansas Living Will
This Living Will is created in accordance with the laws of the State of Arkansas. It expresses an individual's wishes regarding medical treatment and life-sustaining procedures in the event that they become unable to communicate their preferences.
Part 1: Declarant Information
- Name: _______________________________
- Date of Birth: _________________________
- Address: ______________________________
- Phone Number: _________________________
Part 2: Statement of Wishes
If I become unable to make decisions regarding my medical treatment, I wish to provide the following instructions:
- I do not want my life to be prolonged by medical procedures if:
- I have a terminal condition.
- I am in a state of permanent unconsciousness.
- I may wish to receive the following types of medical treatment:
- Resuscitation: Yes / No
- Mechanical Ventilation: Yes / No
- Artificial Nutrition and Hydration: Yes / No
Part 3: Designation of Health Care Representative
If desired, I hereby designate the following person to make health care decisions on my behalf:
- Name of Health Care Representative: ____________________________
- Phone Number: ______________________________________________
- Relationship: _______________________________________________
Part 4: Signatures
This document must be signed and dated by the Declarant or their representative in the presence of two witnesses or a notary public.
Declarant Signature: ______________________ Date: _______________
Witness Signature: ______________________ Date: _______________
Witness Signature: ______________________ Date: _______________
or
Notary Public Signature: ______________________ Date: _______________
My commission expires: ________________________