Texas Living Will Declaration
This is a Living Will Declaration created in accordance with the Texas Health and Safety Code, Chapter 166.
PERSONAL INFORMATION
- Name: ________________________________
- Date of Birth: ______________________
- Address: ____________________________
- Phone Number: ______________________
- Email: _____________________________
DIRECTIVES
I, [Your Name], being of sound mind, willfully and voluntarily make this declaration regarding my medical care preferences if I become unable to communicate my wishes.
In the event that I am diagnosed with a terminal condition or an irreversible condition, I declare the following:
- I do not wish to receive life-sustaining treatments if I am unable to communicate my wishes.
- I would like to receive palliative care to keep me comfortable.
- If I am in a persistent vegetative state, I do not wish to prolong my life through artificial means.
DESIGNATION OF AGENT
If I am unable to make decisions regarding my medical treatment, I appoint the following individual as my healthcare agent:
- Name of Agent: ________________________________
- Address: ___________________________________
- Phone Number: ______________________________
- Email: ____________________________________
The person I designate as my agent should follow the medical treatment decisions I have indicated in this declaration.
WITNESS STATEMENT
This Living Will should be signed in the presence of two witnesses who are not related to me by blood or marriage, and who will not benefit from my estate.
Witness 1:
- Name: ________________________________
- Signature: ___________________________
- Date: ________________________________
Witness 2:
- Name: ________________________________
- Signature: ___________________________
- Date: ________________________________
NOTARY ACKNOWLEDGMENT
State of Texas
County of ____________________
On this ____ day of ____________, 20____, I, ____________________, a Notary Public, hereby certify that the above individual personally appeared before me and declared this document to be their Living Will.
Notary Signature: _______________________
My Commission Expires: _________________