Georgia Living Will Template
This Living Will is designed in accordance with the Georgia Advance Directive for Health Care Act. It allows you to express your wishes regarding medical treatment, in the event that you are unable to communicate these desires yourself.
Principal Information:
- Full Name: ________________________________________
- Date of Birth: ________________________________________
- Address: ________________________________________
- City, State, Zip: ________________________________________
- Telephone Number: ________________________________________
Treatment Preferences
Please specify your treatment preferences below:
- Do Not Resuscitate (DNR) Order:
- Artificial Nutrition and Hydration (Feeding Tube):
- Administer Always ☐
- Administer Only if Life Expectancy is Greater than 6 Months ☐
- Do Not Administer ☐
- Pain Relief:
- Provide all available pain relief measures even if it may hasten my death ☐
- Provide pain relief as needed with consideration for life prolongation ☐
Health Care Agent
If you choose to appoint a Health Care Agent to make health care decisions on your behalf, please provide their information below:
- Agent's Full Name: ________________________________________
- Relation to You: ________________________________________
- Agent's Address: ________________________________________
- Agent's Telephone Number: ________________________________________
Alternate Health Care Agent
In the event your primary Health Care Agent is unable or unwilling to act on your behalf, you may designate an alternate agent:
- Alternate Agent's Full Name: ________________________________________
- Relation to You: ________________________________________
- Alternate Agent's Address: ________________________________________
- Alternate Agent's Telephone Number: ________________________________________
By signing below, you affirm that the choices noted above reflect your desires concerning your health care. You understand that this document can only be revoked or altered by you, and it will remain in effect until such action is taken.
Principal's Signature: ________________________________________ Date: ____________
Witness #1 Signature: ________________________________________ Date: ____________
Witness #1 Printed Name: ________________________________________
Witness #2 Signature: ________________________________________ Date: ____________
Witness #2 Printed Name: ________________________________________