Georgia Living Will Template
This Living Will is created pursuant to the laws of the State of Georgia. It allows you to express your wishes regarding medical treatment in the event you become unable to communicate those wishes yourself.
Personal Information:
- Full Name: _________________________________________
- Address: _________________________________________
- City, State, Zip: ________________________________
- Date of Birth: _____________________________________
- Phone Number: ____________________________________
Declaration:
I, the undersigned, being of sound mind, willfully and voluntarily make this declaration in the event I am diagnosed with a terminal condition or is in a persistent vegetative state.
Healthcare Provisions:
- I direct that my healthcare providers and family to follow my wishes regarding the withholding or withdrawal of life-sustaining treatment if I am in a terminal condition.
- I wish to receive the following medical treatments (check all that apply):
- ☐ Resuscitation
- ☐ Mechanical ventilation
- ☐ Tube feeding
- ☐ Other: ___________________________________________
- If I cannot communicate my wishes, I appoint the following person as my healthcare surrogate:
- Name: _________________________________________
- Address: ______________________________________
- Phone Number: ________________________________
Signature:
I understand that this Living Will expresses my wishes concerning my healthcare decisions. I have signed this Living Will voluntarily, and I intend for it to be legally binding.
Signature: _____________________________________________
Date: ______________________________________________
Witnesses:
- Witness 1: ________________________________________
- Witness 2: ________________________________________
Signature of Witness 1: ______________________________________
Signature of Witness 2: ______________________________________