NOVA SOUTHEASTERN UNIVERSITY
HEALTH PROFESSIONS DIVISION
I have filled out a Living Will/Advance Directive and my designee is
_____________________________.
I have not filled out a Living Will/Advance Directive; however, I will review the
example given to me and may do so at a later time.
I have not filled out a Living Will/Advance Directive and do not wish to do so.
By my signature I acknowledge that I have been given information on my rights
to refuse any medical or surgical treatment that I may not want. I have also been
given information on Patient Directives and I understand that my care will not be
compromised by whether or not I sign a Directive.
___________________________ ________________________________
Witness Patient Name
________________________________
Patient Signature
________________________________
Date
