Ohio Living Will Declaration
This document is a Living Will Declaration made in accordance with Ohio Revised Code §§ 2133.01 to 2133.24. This declaration outlines your wishes regarding medical treatment in situations where you are no longer able to communicate your preferences.
Personal Information:
- Name: ___________________________
- Date of Birth: ____________________
- Address: _________________________
- City, State, Zip: ________________
Statement of Intent:
I, the undersigned, declare this to be my Living Will. I wish to express my preferences for medical treatment if I become terminally ill or permanently unconscious and unable to communicate my wishes.
Preferences Regarding Medical Treatment:
- If I am in a terminal condition, I do not wish to receive treatment that will only prolong the dying process.
- If I am in a persistent vegetative state, I do not wish to receive life-sustaining treatment, except for comfort measures.
- Additionally, I would like to provide the following specific instructions: ___________________________.
Appointment of Health Care Agent:
I designate the following person as my health care agent, who is authorized to make decisions on my behalf regarding medical treatment:
- Name: ___________________________
- Relationship: ____________________
- Phone Number: ___________________
Signature:
By signing below, I confirm that I understand the contents of this Living Will Declaration and that it accurately represents my wishes.
Signature: ___________________________
Date: _________________________________
Witnesses:
Two witnesses must sign below. They must be at least 18 years old and cannot be your health care provider or your health care agent.
- Witness 1 Name: ___________________________
- Signature: _________________________________
- Date: ____________________________________
- Witness 2 Name: ___________________________
- Signature: _________________________________
- Date: ____________________________________
This Living Will takes effect only when I am unable to communicate my wishes regarding medical treatment. I understand that I can revoke or change this document at any time while I am of sound mind.