Arizona Living Will Template
This Living Will is made in accordance with Arizona state laws regarding advance directives. It allows you to express your wishes regarding medical treatment in the event that you are unable to communicate those wishes yourself. Please fill in the blanks with your information.
PART 1: PERSONAL INFORMATION
Full Name: _______________________________________
Date of Birth: ____________________________________
Address: ________________________________________
City, State, Zip: _________________________________
PART 2: DECLARATION
I, the undersigned, hereby declare that if I become unable to communicate my healthcare decisions, I wish to provide guidance to my healthcare providers as follows:
PART 3: MEDICAL TREATMENT PREFERENCES
- In the event of a terminal illness or condition, I do not wish to receive:
- Cardiopulmonary resuscitation (CPR)
- Artificial nutrition and hydration
- Mechanical ventilation
- If I am in a persistent vegetative state, I wish to receive:
- Comfort care only
- Do not resuscitate (DNR) status
- Other preferences: _____________________________________
PART 4: DESIGNATION OF HEALTHCARE AGENT
I designate the following person as my healthcare agent to make medical decisions on my behalf if I am unable to do so:
Name: _______________________________________________
Relationship: ________________________________________
Phone Number: _______________________________________
PART 5: SIGNATURE
I understand the contents of this Living Will and the effect it has on my medical treatment. I sign this document willingly and without reservation.
Signature: ___________________________________________
Date: ________________________________________________
WITNESSES
This Living Will must be signed in the presence of two witnesses:
Witness 1: ________________________________________
Witness 1 Signature: _______________________________
Date: ____________________________________________
Witness 2: ________________________________________
Witness 2 Signature: _______________________________
Date: ____________________________________________
It is recommended that you keep a copy of this Living Will with your medical records and share it with your healthcare agent and family members.