Suggested form of a Living Will, Florida Statutes 765.303
Florida Living Will
Declaration made this ____ day of __________________, ________, I,________________________,
willfully and voluntarily make known my desire that my dying not be artificially prolonged under the
circumstances set forth below, and I do hereby declare that, if at any time I am incapacitated and
_____ (initial) I have a terminal condition, or
_____ (initial) I have an end-stage condition, or
_____ (initial) I am in a persistent vegetative state
and if my primary physician and another consulting physician have determined that there is no
reasonable medical probability of my recovery from such condition, I direct that life-prolonging
procedures be withheld or withdrawn when the application of such procedures would serve only to
prolong artificially the process of dying, and that I be permitted to die naturally with only the
administration of medication or the performance of any medical procedure deemed necessary to
provide me with comfort care or to alleviate pain.
It is my intention that this declaration be honored by my family and physician as the final expression of
my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.
In the event that I have been determined to be unable to provide express and informed consent
regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to
designate, as my surrogate to carry out the provisions of this declaration:
Name: ___________________________________________________________________________
Address: _________________________________________________________________________
Phone: __________________________________________________________________________
I understand the full import of this declaration, and I am emotionally and mentally competent to make
this declaration.
Additional Instructions (optional): ______________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
(Signed) ___________________________________
Witness ______________________________ Witness ___________________________________
Print Name ___________________________ Print Name _________________________________
Address ______________________________ Address ___________________________________
_____________________________________ __________________________________________
Witness must not be a husband, wife, or a blood relative of the principal.
A health care surrogate cannot act as a witness.
Your attorney or health care provider may be able to assist you with forms or further information.
