California Living Will
This document is a Living Will under California law. It allows you to express your preferences regarding medical treatment in the event that you become unable to make your own healthcare decisions.
Personal Information:
Name: _________________________________________
Date of Birth: ___________________________________
Address: ________________________________________
Phone Number: _________________________________
Healthcare Preferences:
If I become terminally ill or permanently unconscious, I wish to make the following preferences known regarding my medical treatment:
- 1. I do not wish to receive life-sustaining treatments if:
- a. I am unable to communicate my wishes.
- b. There is no reasonable expectation of recovery.
- 2. I would like to receive comfort care, including:
- a. Pain management.
- b. Emotional support.
- 3. I would like to have the following people involved in my care decisions:
- a. Name: ___________________________________________
- b. Phone Number: ___________________________________
Signature:
By signing below, I confirm that I understand the contents of this Living Will and that I am making these health care decisions willingly.
Signature: _________________________________________
Date: ______________________________________________
Witnesses:
Two witnesses must be present at the time of signing. They cannot be family members or anyone named in this document.
- Witness Name: ___________________________________
- Signature: _______________________________________
- Date: ___________________________________________
- Witness Name: ___________________________________
- Signature: _______________________________________
- Date: ___________________________________________
This Living Will should be kept in a safe place and copies should be provided to your healthcare provider and family members.