Georgia Living Will
This Living Will is created in accordance with the Georgia Advance Directives for Health Care Act (O.C.G.A. § 31-32-1 et seq.). It sets forth your desires regarding medical treatment in the event you become unable to communicate your wishes.
Personal Information
- Your Name: ____________________________
- Your Address: ____________________________
- Your Phone Number: ____________________________
- Date of Birth: ____________________________
Directive Statement
If I become terminally ill or permanently unconscious, I direct that my healthcare providers follow the medical decisions outlined below:
- I wish to receive comfort care, including pain relief, even if it may hasten my death.
- I do not wish to receive life-sustaining treatment if my condition is terminal.
- If I am in a persistent vegetative state, I do not want extraordinary measures taken to prolong my life.
Healthcare Agent Designation
I designate the following individual as my healthcare agent to make medical decisions on my behalf if I am unable to do so:
- Name of Healthcare Agent: ____________________________
- Address of Healthcare Agent: ____________________________
- Phone Number of Healthcare Agent: ____________________________
This designation becomes effective upon my incapacity.
Signatures
By signing below, I affirm that I understand the contents of this Living Will and that my decisions reflect my wishes:
- Signature: ____________________________
- Date: ____________________________
Witnesses
This document must be witnessed by two individuals, neither of whom can be my healthcare agent:
- Witness 1 Name: ____________________________
- Witness 1 Signature: ____________________________
- Date: ____________________________
- Witness 2 Name: ____________________________
- Witness 2 Signature: ____________________________
- Date: ____________________________
This Living Will remains in effect until revoked by me in writing.