Georgia Living Will
This Living Will is created in accordance with the laws of the State of Georgia. It outlines your wishes regarding medical treatment in the event that you become unable to communicate your preferences.
Personal Information
- Name: ___________________________
- Date of Birth: ____________________
- Address: _________________________
- City, State, Zip Code: ____________
Declaration
I, the undersigned, being of sound mind, willfully and voluntarily make this declaration. If I become unable to make my own healthcare decisions, I wish to express my preferences regarding medical treatment as follows:
- If I am diagnosed with a terminal condition, I do not wish to receive life-sustaining treatment.
- If I am in a persistent vegetative state, I do not wish to receive life-sustaining treatment.
- If I am diagnosed with a condition that will result in my death within a short period of time, I do not wish to receive life-sustaining treatment.
Additional Instructions
Please specify any additional wishes or instructions regarding your medical treatment:
_____________________________________________________________________
_____________________________________________________________________
Appointment of Healthcare Agent
I hereby designate the following individual as my healthcare agent to make decisions on my behalf if I am unable to do so:
- Name of Agent: ______________________
- Relationship to Agent: _______________
- Contact Information: _________________
Signature
By signing below, I affirm that I am of legal age and mentally competent to make this declaration.
Signature: ____________________________
Date: _________________________________
Witnesses
This declaration must be witnessed by two individuals who are not related to you and who will not benefit from your estate.
- Witness 1 Name: _____________________
- Witness 1 Signature: ________________
- Witness 2 Name: _____________________
- Witness 2 Signature: ________________