Client Name *

First Name

Last Name

END OF LIFE DECISIONS:

Choice NOT to Prolong Life: I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits,

Choice TO Prolong Life: I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.

PAIN MANAGEMENT - Alleviation of pain or discomfort be provided at all times, even if it hastens my death.

Yes

No

PRIMARY PHYSICIAN

Optional. Only choose if you would like your physician to take charge of your care in case of hospitalization.

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

ORGAN DONOR

Yes, any and all organs.

Specific organs only

Donate for purpose of:

Transplant

Therapy

Research

Education

FUNERAL AND BURIAL WISHES

Cremation

Burial

Memorial Service

Religious

Non-Religious

Other