Advance Directive for Health Care - Short Form

Use this form to create an Advance Directive for your health care. It is three pages long.

Use this text or the fillable PDF form below the text.

Learn more on our Advance Directives page.

ADVANCE DIRECTIVE FOR HEALTH CARE

Your Name: [Write your name]

Date of Birth: [Write your date of birth]

Address: [Write your address]

YOUR HEALTH CARE AGENT

Your health care agent can make health care decisions for you when you cannot make decisions for yourself. You should pick someone that you trust. Talk to them about your wishes. Tell them that you are making them your agent in this advance directive.

I want this person to be my healthcare agent.

Name: [Write the name of the person to be agent]

Address: [Write their address]

Phone Home: [Write their home phone number]

Work Phone: [Write their work phone number]

Cell Phone: [Write their cell phone number]

Email: [Write their email address]

I want this person to be my alternate agent if the first person cannot do it.

Name: [Write the name of the alternate person to be agent]

Address: [Write their address]

Phone Home: [Write their home phone number]

Work Phone: [Write their work phone number]

Cell Phone: [Write their cell phone number]

Email: [Write their email address]

I want my advance directive to start:

[Select one of the following]

When I cannot make my own decisions

Now

When this happens: [Describe the event]

YOUR TREATMENT WISHES

You can write down what kind of medical treatment you want or do not want in this section. These are your choices. Talk to your doctor if you have questions.

My wishes for end of life care (initial your choices):

[Write your initials next to the following choices]

I want all possible medical treatment to sustain life.

I do not want the following medical treatment (check your choices):

  • breathing machine
  • feeding tube
  • food by I.V. (intravenously)
  • fluid by I.V. (intravenously)
  • other treatments

I do not want any medical treatment to extend my life.

I want care that preserves my dignity and provides comfort and relief from pain and other symptoms that bother me. I want pain medication even if it might make me die sooner.

Other Wishes:

[Write any other wishes]

I plan to give a copy of my advance directive to:

[Check your choices]

My agent. They have agreed to be my agent: Yes / No. [Select yes or no]

My doctor

The online registry

Other: [Write where a copy will go.]

SIGNATURE AND WITNESSES

You must sign this before two adult witnesses. Your agent, spouse, partner, brother, sister, parent, child, grandchild, or reciprocal beneficiary cannot be a witness.

You must sign and date the Advance Directive.

These are my wishes regarding my medical care. I am signing this advance directive of my own free will.

Sign your name here [Sign your name]

Date [Write the date]

Your witnesses must sign and date the Advance Directive.

I affirm that the Principal appeared to understand the nature of this advance directive and to be free from duress or undue influence at the time this was signed.

First Witness Signature [First witness signs here]

Date [Write the date]

Print name [Print first witness name]

Address (Town, State) [Write their address]

 

Second Witness Signature [Second witness signs here]

Date [Write the date]

Print name [Print second witness name]

Address (Town, State) [Write their address]

Patients and residents of hospitals, nursing homes, or residential care homes must have this section signed.

I explained the nature and effect of this advance directive to the Principal.

Signature of Ombudsman/Clergy/Attorney/Court Designee/Hospital Representative [They sign here]

Date [Write the date]

 

Attachment Size
Advance-Directive-Short-Form(fully-accessible).pdf133.22 KB 133.22 KB

Source URL: https://vtlawhelp.org/advance-directive-health-care-short-form

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