Living Will

1

What is your full legal name?* This field is required.

First Middle Last Suffix (Jr., Sr., III, etc.)

2

What is your biological gender?* This field is required.

Male

Female

3

Please note that some states invalidate a Living Will made while pregnant. If you are pregnant, please consult your state's laws or an estate-planning attorney.

4

The next question will ask you whether you want to include a Power of Attorney for Health Care in addition to your Living Will. A Living Will states your health care preferences and instructions only after you become terminally ill or permanently incapacitated. A Power of Attorney for Health Care allows you to appoint someone to make health care decisions on your behalf, and can take effect immediately or whenever else you specify. Selecting "yes" in the following question will include basic Power of Attorney for Health Care provisions. If you want to specify more detailed instructions for your health care agent, please select "no" here and create a separate Power of Attorney for Health Care document.

5

Do you want to include a Power of Attorney for Health Care?* This field is required.

YESNO

6

Okay, the next few questions will ask you to appoint a health care agent and at least one alternate agent. Generally, your health care agent must be at least 18 years old. If you live in Alabama or Nebraska, your agent must be at least 19 years old. If you live in Colorado, your agent must be at least 21 years old. Further, many state laws prevent your physician or health care provider from being your agent. Please consult with an estate-planning attorney for more information specific to your state of residence. Be sure to provide your agent's contact information so that your agent may be contacted promptly.

7

Please enter the name and contact information of your agent.* This field is required.

8

Please enter the name and contact information of an alternate health care agent, in case the agent you just named is unable or refuses to serve as your agent.* This field is required.

9

Would you like to name a second alternate agent, in case the agent and the alternate are both unable or unwilling to serve as your health care agent?* This field is required.

YESNO

10

Please enter the name and contact information of your second alternate health care agent.* This field is required.

11

The next question will ask when your agent's authority should start. You can choose "immediately," "only if I become temporarily or permanently incapable of making my own health care decisions," or "other." If you choose "other," you will be asked to write-in a response.

12

When should your agent's authority to make decisions on your behalf start?

Immediately

Only if I become temporarily or permanently incapable of making my own health care decisions

Other - as I state in the next question

13

You selected "other." Please describe when you would like your agent's authority to start.

14

Your agent will be authorized to make all health care decisions on your behalf to the same extent you could, unless you specifically limit your agent's authority. The next question will ask whether you would like to do so. You can, for example, write that your agent does not have the authority to withdraw artificial nutrition and hydration if doing so would hasten your death.

15

Would you like to limit your agent's authority to make health care decisions on your behalf?

YESNO

16

How should your agent's authority be limited?

17

Your agent will also be authorized to make anatomical gifts (i.e., donate your organs), authorize an autopsy, and direct the disposition of your remains (i.e., choose to bury or cremate you), unless you specifically limit your agent's authority. The next question will ask whether you would like to do so. If your Last Will & Testament states your instructions regarding your remains and any funeral or memorial service, consider selecting "yes" in the next question and writing "Please follow the instructions I've left in my Last Will & Testament regarding my remains and final services" in the question after that. This is because your Last Will may not be read until a few days after your death, whereas your Living Will should be read as soon as you sign it.

18

Would you like to limit your agent's authority in this regard?

YESNO

19

How should your agent's post-death authority be limited?

20

Okay, the next few questions will ask you about your health care preferences and instructions.

21

Please remember that a Living Will is not the same thing as a DNR, or a Do-Not-Resuscitate Order. A DNR is an order signed by a doctor that says the patient does not want to be resuscitated or revived. For example, with a DNR, you will not receive CPR if you stop breathing. A DNR may be appropriate if quality of life is low. Please consult with your medical provider.

Your Living Will can state that you want a DNR, but you will need to show your Living Will to a medical provider in order to obtain a DNR and a bracelet that informs emergency medical personnel not to revive you.

22

First, we will ask you whether you would want your life to be prolonged "no matter what"--i.e., if you become permanently incapacitated. Your state may have laws that would govern your care in this scenario unless you state your preferences. Please review your state's laws or consult with a health care attorney. If you do want your life to be prolonged in the event of incapacitation, such treatment must still be within generally accepted health care standards.

23

Do you want your life to be prolonged as long as possible within the limits of generally accepted health care standards?* This field is required.

YESNO

24

When would you not want your life to be prolonged? Select one or more.

If I have an incurable or irreversible condition that will result in my death

If I become unconscious and--to a reasonable degree of medical certainty--I will not regain consciousness

If the likely risks and burdens of treatment would outweigh the expected benefits

Other

25

By default, your Living Will states that you want pain-relieving treatment to be provided even if it hastens your death. If you want to change this instruction, please select "yes" in the next question.

26

Do you want to change the instruction that pain-relieving treatment be provided even if it hastens your death?* This field is required.

YESNO

27

How should this instruction be modified or limited?

28

The next question will ask you about what you would want to have happen if you are pregnant and become permanently incapacitated. You will be asked whether you would want life-sustaining treatment to continue to be applied if it is medically possible for the fetus to develop to the point of live birth with such treatment. Remember, some states invalidate a Living Will made while pregnant. If you are pregnant, please consult your state's laws or an estate-planning attorney.

29

Do you want life-sustaining treatment to be provided if you are pregnant and incapacitated?

YESNO

30

Do you want to specify any other health care wishes or instructions?* This field is required.

YESNO

31

What other wishes or instructions do you want to provide?

32

Would you like to donate your body or specific organs?* This field is required.

YESNO

33

Please select one of the following.

Donate my entire body

Donate any needed organs, tissues, or parts

Donate the organs, tissues, or parts I specify

34

Please describe the organs, tissues, or parts you want to donate.

35

For what purpose(s) should your body, organs, tissues, or parts be used? Select one or more.

Transplantation

Research

Education

Therapy

36

Do you want to designate a primary or specialist physician?* This field is required.

YESNO

37

What is your primary physician's contact information?* This field is required.

38

The next question will ask you if you want to name an alternate primary physician. This can be useful if the primary physician you listed is unable, unwilling, or unavailable to act.

39

If you want to name an alternate primary physician, please do so here.

40

Do you want to designate a specialist physician as your preferred specialist in his/her practice area?* This field is required.

YESNO

41

What is your specialist's practice area and contact information?* This field is required.

42

Do you want to designate another specialist?* This field is required.

YESNO

43

What is your specialist's practice area and contact information?* This field is required.

44

Do you want to designate another specialist?* This field is required.

YESNO

45

What is your specialist's practice area and contact information?* This field is required.

46

The next question will ask you if you want to name an alternate specialist physician. This can be useful if the specialist you listed is unable, unwilling, or unavailable to act.

47

If you want to name an alternate specialist, what is his/her/their practice area and contact information?

48

Do you want to designate another alternate specialist?* This field is required.

YESNO

49

What is your alternate specialist's practice area and contact information?* This field is required.

50

Do you want to designate another alternate specialist?* This field is required.

YESNO

51

What is your alternate specialist's practice area and contact information?* This field is required.

52

What State do you live in?* This field is required.

53

What city do you live in?* This field is required.

54

Please list your email address. We will send your Living Will and execution instructions to this address.* This field is required.

example@example.com

Confirm Email

55

Feel free to list your phone number in case we need to contact you.

Area Code

Phone Number

56

Finally, please review and accept our Terms of Use and Privacy Policy.* This field is required.