Vermont Living Will Template
This Living Will is created in accordance with the laws of the State of Vermont. It expresses my wishes regarding medical treatment in the event that I become unable to make decisions for myself.
Personal Information:
- Name: _______________________________
- Date of Birth: _______________________
- Address: _____________________________
- City/State/Zip: ______________________
- Phone Number: ________________________
Declaration:
I, the undersigned, being of sound mind, willfully and voluntarily make this declaration to guide my health care providers and family regarding my medical treatment preferences. In the event that I am unable to make my own decisions due to illness or incapacity, I wish to express my preferences concerning life-sustaining treatment.
My wishes regarding medical treatment are as follows:
- If I have a terminal condition or am in a persistent vegetative state, I do not want my life to be prolonged by artificial means.
- I wish to receive pain relief even if it may hasten my death.
- Under any circumstances where I am unable to communicate, I would like to have the option of not being resuscitated.
Appointment of Healthcare Agent:
If I am unable to make healthcare decisions for myself, I designate the following person as my healthcare agent:
- Name: _______________________________
- Relationship: _________________________
- Phone Number: ________________________
- Address: _____________________________
Revocation:
This Living Will may be revoked at any time by notifying my healthcare providers in writing or verbally. It is my intent that this document remain in effect until revoked.
Signatures:
In witness whereof, I have signed this Living Will on this _____ day of __________, 20__.
Signature: _______________________________
Witness 1: ______________________________
Witness 2: ______________________________
Notary Public (optional):
State of Vermont, County of ________________
Subscribed and sworn to before me this _____ day of __________, 20__.
Notary Signature: ________________________
My commission expires: ___________________