Advance Directive Template

Information you will need

• Cardiopulmonary Resuscitation CPR
• Ventilation breathing machine
• Feeding tube
• Dialysis
• Other
• Date Completed (Current Date)
• Principal City
• Principal Street Address
• Principal County
• Principal State
• Principal Last 4 SSN
• Initial: Chronic Coma / Vegetative State
• Initial: Can't Communicate
• Initial: Can't Recognize Family/Friends
• Initial: Total Dependence on Others
• Initial: Other
• Check: Can't Communicate
• Check: Can't Recognize Family/Friends
• Check: Total Dependence on Others
• Check: Other
• Other Unnacceptable Quality of Life
• Choose one: Receive Food & Water
• Choose one: NOT Receive Food & Water
• Optional: CPR

…and 33 more fields in the PDF.

Completed by the agent and the principal and the provider.

The form includes 3 signature lines, a notary acknowledgment, a witness section.