Advance Directive for Life-Sustaining Treatment Form
Document your treatment preferences and designate a decision-maker in case you are unable to communicate. Please complete all applicable sections.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Surrogate/Decision-Maker Name
First Name
Last Name
Surrogate/Decision-Maker Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Life-Sustaining Treatment Preferences
*
I want all available life-sustaining treatments
I want some life-sustaining treatments (see comfort-care priorities)
I do not want life-sustaining treatments
Other (please specify below)
Comfort-Care Priorities (e.g., pain management, spiritual care, being at home)
Additional Instructions or Preferences
Signature (please sign to confirm your preferences)
*
Submit Advance Directive
Submit Advance Directive
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