Arizona Living Will Template
This Arizona Living Will complies with Title 36, Chapter 32 of the Arizona Revised Statutes, which is specific to the state of Arizona and its guidelines on health care directives.
Please fill in the following information to complete your Arizona Living Will:
Full Legal Name: ___________________________________________________
Date of Birth: ___________________________________________________
Address: ___________________________________________________
City/Town: ___________________________________________________
State: Arizona
Zip Code: ___________________________________________________
Telephone Number: ___________________________________________________
Email Address (Optional): ___________________________________________________
Health Care Directives
In the event that I am incapacitated and cannot communicate my health care wishes, I direct that:
- My health care providers shall prolong my life as long as possible within the limits of generally accepted health care standards.
- In the case that I am in a coma or vegetative state with no reasonable chance of recovery, as determined by two independent physicians, I do or do not want life-sustaining treatment to be provided or continued.
- I do or do not want to receive food and water (nutrition and hydration) artificially provided.
- In the event of a terminal condition, I do or do not want to receive treatment that only serves to delay the moment of death.
Additional Instructions
Please provide any additional instructions or health care wishes you have not previously specified:
______________________________________________________________________________
______________________________________________________________________________
Designation of Health Care Agent
If I am unable to communicate my health care decisions, I designate the following person as my Health Care Agent:
Name: ___________________________________________________
Relationship: ___________________________________________________
Address: ___________________________________________________
Telephone Number: ___________________________________________________
This designation revokes any previous designations of a health care agent.
Signature
To ensure the validity of this document, please provide the following:
Date: ___________________________________________________
Signature: ___________________________________________________
Printed Name: ___________________________________________________
Witness Statement
This Living Will was signed in my presence and the principal appeared to be of sound mind and free from duress.
Witness Name: ___________________________________________________
Witness Address: ___________________________________________________
Date: ___________________________________________________
Witness Signature: ___________________________________________________