Texas Living Will
This Living Will is created in accordance with Texas state laws regarding advance directives. Please fill in the information below.
Declarant Information:
- Full Name: ___________________________
- Date of Birth: _______________________
- Address: _____________________________
- City, State, ZIP: ____________________
By signing this document, I am expressing my wishes concerning medical treatments and procedures in the event that I am unable to communicate my decisions.
PART A: Declaration of Wishes
- If I become terminally ill, I do not want my life to be prolonged by medical means. (Initial: ____)
- If I am in a persistent vegetative state and there is no reasonable expectation of recovery, I do not want my life to be prolonged. (Initial: ____)
- I choose to receive comfort care and palliative care to alleviate pain and suffering, even if that care may hasten my death. (Initial: ____)
PART B: Specific Instructions
Please list any additional instructions regarding your treatment below:
____________________________________________________________
____________________________________________________________
PART C: Signatures
By signing below, I affirm that I am of sound mind and over the age of 18, and I understand the implications of this document.
- Signature of Declarant: ______________________
- Date: ______________________
In accordance with Texas law, this Living Will must be signed in the presence of at least two witnesses or a notary public:
- Witness 1 Signature: ______________________
- Witness 1 Printed Name: ______________________
- Date: ______________________
- Witness 2 Signature: ______________________
- Witness 2 Printed Name: ______________________
- Date: ______________________
Note: Witnesses cannot be related by blood or marriage to the Declarant, and cannot be entitled to any part of the Declarant's estate.