Virginia Living Will
This Living Will is created in accordance with the laws of Virginia. It allows you to express your wishes regarding medical treatment if you become unable to communicate.
Individual Information
- Name: ________________________
- Date of Birth: _________________
- Address: ______________________
- City: __________________________
- State: _________________________
- Zip Code: ______________________
Statement of Wishes
If I am diagnosed with a terminal condition or an irreversible condition, I wish to provide the following instructions regarding my medical care:
- In the event I am unable to make my own medical decisions, I request the following:
- Do not resuscitate me (DNR) under any circumstances.
- Palliative care should be provided to keep me comfortable.
- Alternatively, other preferences for medical treatment include:
- ____________________________________________________________________
- ____________________________________________________________________
Durable Power of Attorney for Health Care
If I have not designated a person to make decisions on my behalf, I authorize the following person to act for me in making medical decisions:
- Name of Agent: ________________________
- Phone Number: ________________________
- Address: ______________________________
Signatures
This Living Will shall be effective as of the date signed below.
Signature: ___________________________
Date: _________________________________
Witness 1: ___________________________
Date: _________________________________
Witness 2: ___________________________
Date: _________________________________
It is recommended to keep this document in an easily accessible location and share your wishes with family and health care providers.