Texas Living Will
This Living Will is created in accordance with the laws of the state of Texas. It serves to declare your wishes regarding medical treatment in the event that you become unable to communicate your preferences.
Individual Information
- Name: ________________________
- Date of Birth: ________________________
- Address: ________________________
- City: ________________________
- State: ________________________
- ZIP Code: ________________________
Declaration
I, the undersigned, being of sound mind, do hereby make this declaration to serve as my Living Will. If I become unable to participate in my medical care, I direct that my wishes apply to the following situations:
- In the event that I face a terminal condition, I do not wish to receive life-sustaining treatment, if, in my physician’s judgment, the treatment would only prolong the process of dying.
- In cases of irreversible or persistent vegetative state, I wish to forego treatments that serve only to prolong the dying process.
Other specific wishes regarding my medical treatment: ______________________________________
Appointment of Health Care Agent
If applicable, I designate the following person to make health care decisions on my behalf:
- Name of Agent: ________________________
- Phone Number: ________________________
- Address: ________________________
Signatures
By signing below, I affirm that I understand the contents of this Living Will and that this document represents my wishes regarding my medical treatment.
- Signature: ________________________
- Date: ________________________
This Living Will may be revoked or modified at any time, provided that the revocation or modification is documented in writing and dated.