Texas Living Will
This Living Will is made in accordance with Texas laws, specifically Texas Health and Safety Code, Section 166.032.
Principal Information:
- Name: __________________________________________
- Date of Birth: _____________________________________
- Address: _________________________________________
- City, State, Zip Code: _________________________
Instructions: This document states your wishes regarding medical treatment in case you cannot communicate them due to illness or injury.
Part 1: Declaration
I, the undersigned, declare that if I have a terminal or irreversible condition and am unable to communicate, I wish to make the following choices:
- Allow the following treatments to be withheld or withdrawn: ____________
- Do not administer artificial nutrition or hydration: ___________
- Other specific wishes: _________________________________
Part 2: Appoint an Agent
If applicable, I appoint the following person to act on my behalf:
- Name: __________________________________________
- Address: ________________________________________
- Phone Number: ___________________________________
Part 3: Signatures
This Living Will must be signed in the presence of two witnesses or a notary public.
Signature of Principal: _______________________________ Date: ____________
Witness 1: _________________________________________ Date: ____________
Witness 2: _________________________________________ Date: ____________
Note: Witnesses cannot be relatives, or individuals entitled to any part of the estate of the Principal.