Ohio Living Will
This document serves as a directive concerning your medical care preferences in the event that you become unable to communicate your wishes. It is created in accordance with Ohio state law.
Instructions: Please fill in the blanks where indicated. Review this document with a trusted individual or legal advisor to ensure it meets your needs.
1. Personal Information:
- Name: ________________________________
- Date of Birth: ________________________
- Address: _____________________________
- Telephone Number: ____________________
2. Designation of Health Care Agent:
I, ______________________________, choose the following person as my Health Care Agent:
- Name of Agent: ______________________
- Address of Agent: ____________________
- Telephone Number of Agent: ____________
3. Statement of Desired Medical Treatment:
If I am diagnosed with a terminal condition or become permanently unconscious, I wish to provide guidance for my health care as follows:
- Accept all forms of treatment necessary to keep me alive.
- Limit treatment to only what is necessary to maintain my dignity and comfort.
- Refuse any treatment that extends the dying process.
4. Special Instructions:
My specific preferences regarding my care are as follows:
______________________________________________________
______________________________________________________
5. Signature and Date:
I hereby affirm that I understand the contents of this Living Will and that I am signing this document voluntarily.
______________________________
Signature
Date: ______________________
6. Witnesses:
This Living Will should be signed in the presence of two witnesses who are not related to me, nor are they entitled to any part of my estate:
- Witness 1: ________________________ Date: _______________
- Witness 2: ________________________ Date: _______________