Fillable Printable Living Will Form - Arizona
Fillable Printable Living Will Form - Arizona
Living Will Form - Arizona
_______________________________________________________________________________________________________________________________
Developed by the Office of the Attorney General Updated January 18, 2011
TOM HORNE (All documents completed before January 18, 2011 are still valid)
www.azag.gov
LIVING WILL
Page 1 of 2
STATE OF ARIZONA
LIVING WILL (End of Life Care)
Instructions and Form
GENERAL INSTRUCTIONS: Use this Living Will form to make decisions now about your medical care if you are ever in a
terminal conditi on, a persistent vegetative state or an irreversible c oma. You should talk to your doctor about what these terms
mean. The Livi ng Will states what choices you would have made for yourself if you were able to communicate. It is your written
directions to your health care representative if you have one, your family, your physician, and any other person who might be
in a position to make medical care decisions for you. Talk to your family members, friends, and others you trust about your
choices. Also, it is a good idea to talk with professionals such as your doctor, clergyperson and a lawyer before you complete
and sign this Living Will.
If you decide this is the form you want to use, complete the form. Do not sign the Living Will until your witness or a Notary
Public is present to watch you sign it. There are further instructions for you about signing on page 2.
IMPORT ANT: If you have a Living Will and a Durable Health Care Pow er of Attorney, you must attach the Living Will
to the Durable Health Care Power of Attorney.
1. Information about me: (I am called the “Principal”)
My Name: ______ ________________________ _________ ___ My Age: ________________________________ _
My Address:_________________________________________ My Date of Birth: ___________________________
________ _______ _____________________________ _______ My Telephone: _________________________ ___
2. My decisions about End of Life Care:
NOTE: Here are some gen eral statements ab out choices you hav e as to h ealth care yo u wa nt at the end of your life. T hey are
listed in the order provided by Arizona law. You can initial any combination of paragraphs A, B, C, and D. If you initial
Paragraph E, do not initial any other paragraphs. Read all of the statements carefully before initialing to indicate your
choice. You can also write your own statement concerning life-sustaining treatments and other matters relating to your health
care at Section 3 of this form.
______ A. Comfort Care Only: If I have a terminal condition I do not want my life to be prolonged, and I do not want life-
sustaining treatment, beyond comfort care, that would serve only to artificially delay the moment of my death. (NOT E: “Comfort
care” means treatment in an attempt to protect and enhance the quality of life without artificiall y prolonging life.)
______ B. Specific Limitations on Medical Treatments I Want: (NOTE: Initial or mark one or more choices, talk to your
doctor about your c hoic es.) If I hav e a termi nal condition, o r am i n an irrev ersible c oma or a persistent v egetativ e state that my
doctors reasonably believe to be irreversible or incurable, I do want the medical treatment necessary to provide care that
would keep me comfortable, but I do not want the following:
____ 1.) Cardiopulmonary resuscitation, for exampl e, the use of drugs, electric shock, and artificial breathing.
_____ 2.) Artificially administered food and fluids.
_____ 3.) To be taken to a hospital if it is at all avoidable.
_______ C. Pregnan cy: Regardless of any other directions I have giv en in this Living Will, if I am kn own to be pr egnant I do
not want life-sustaining treatment withheld or withdrawn if it is possible that the embryo/fetus will develop to the point of live
birth with the continued application of life-s ustaining treatment.
_______ D. Treatment Until My Medical Condition is Reasonably Known: Regardless of the directions I have made in
this Living Will, I do want the use of all medical car e necess ary to treat my c ondition until my doctors reasonably conc lude that
my condition is terminal or is irreversible and incurable, or I am in a persistent vegetative state.
_______ E. Direction to Prolong My Life: I want my life to be prolonged to the greatest extent possible
ST ATE OF ARIZONA LIVING WILL (“End of Life Care”) (Cont’d)
_______________________________________________________________________________________________________________________________
Developed by the Office of the Attorney General Updated January 18, 2011
TOM HORNE (All documents completed before January 18, 2011 are still valid)
www.azag.gov
LIVING WILL
Page 2 of 2
3. Other Statements Or Wishes I Want Followed For End of Life Care:
NOTE: You can attach add itional provisions or limitations on medical care that have not bee n included in this Livin g Will form.
Initial or put a check mark by box A or B below. Be sure to include the attachment if you check B.
_______ A. I have not attached additional special provisions or limitations about End of Life Care I want.
_______ B. I have attached additional special provisions or limitations about End of Life Care I want.
SIGNATURE OR VERIFICATION
A. I am signing this Living Will as follows:
My Signature: __________ _______ ______________________ ____________ Date: _______ ______________________
B. I am physically unable to sign this Living Will, so a witness is verifying my desires as follows:
Witness Verification: I believe that this Living Will accurately expresses the wishes communicated to me by the principal of
this document. He/she intends to adopt this Living Will at this time. He/she is physically unable to sign or mark this document
at this time. I verify that he/she directly ind icated to me that the Living Will express es his/her wishes and that he/she i ntends to
adopt the Living Will at this time.
Witness Name (printed): ____ ________ _______ ______________ _______ ________ _______ _______ _______ _______ ____
Signature: _______________ _______________ _______ _______ ___________ Date: ____________ _______ __________
SIGNATURE OF WITNESS OR NOTARY PUBLIC
NOTE: At least one adult witness OR a Notary Public must witness you signing this document and then sign it. The witness
or Notary Public CANNOT be anyone who is: (a) under the age of 18; (b) related to you by blood, adoption, or marriage; (c)
entitled to any part of your estate; (d) appointed as your representative; or (e) involved in providing your health care at the time
this document is signed.
A. Witness: I certify that I witnessed the signi ng of this document by the Principal. The pers on who signed this Living Will
appeared to be of sound min d and under no pressur e to make specific choices or sign the document. I understand the
requirements of being a witness. I confirm the following:
ƇI am not currently designated to make medical decisions for this person.
ƇI am not directly involved in administering health car e to this person.
ƇI am not entitled to any portion of this person’s estate upon his or her death under a will or by operatio n of law.
ƇI am not related to this person by blood, marriage, or adoption.
Witness Name (printed): _________ ______________ _______________ ______________ _______ ________________
Signature: __________________________________ ________________________ Date: ______________________
Address: _____________________ _____________________________ ______________ _______________ _________
B. Notary Public: (NOTE: a Notary Public is only required if no witness signed above)
STATE OF ARIZONA ) ss
COUNTY OF _________ _______ _______ _____ )
The undersigned, being a Nota ry Public certified in Arizona, dec lares that the person making this Living Will has dated and sig ned or marked it
in my presence, and appears to me to be of sound mind and free from duress. I further declare I am not related to the person signing above, b y
blood, marriage or adoption, or a person designated to make medical decisions on his/her behalf. I am not directly involved in providing health
care to the person signing. I am not entitled to any part of his/her estate under a will now existing or by operation of law. In the event the
person acknowledging this Living Will is physically unable to sign or mark this document, I verify that he/she directly indicated to me that the
Living Will expresses his/her wishes and that he/she intends to adopt the Living Will at this time.
WITNESS MY HAND AND SEAL this _______ day of ____________________, 20____.
Notary Public: ___ _______ _______ _______________ _______ _________ My commission expires: _______ _______ _______
