Georgia Living Will
This Living Will is designed to express the wishes of the undersigned regarding healthcare decisions in accordance with the Georgia Advance Directive for Health Care Act.
Part I: Personal Information
Full Name: ___________________________________________________
Date of Birth: ________________________________________________
Address: _____________________________________________________
City: ______________________ State: Georgia Zip: _______________
Telephone Number: ____________________________________________
Part II: Appointment of Health Care Agent
I, ____________________________, hereby appoint the following individual as my Health Care Agent to make health care decisions for me:
Name of Health Care Agent: ___________________________________
Relationship to me: __________________________________________
Primary Phone: ___________________ Alternate Phone: ____________
Address of Health Care Agent: _________________________________
Part III: Treatment Preferences
This section outlines my wishes regarding life-sustaining treatments, artificial nutrition, and hydration.
- I wish to receive life-sustaining treatments:
- If my condition is terminal and treatment would only prolong the dying process
- If I am in a persistent vegetative state
- If I have an irreversible condition that will result in my death
- Preferences regarding artificial nutrition and hydration:
- I wish to receive artificial nutrition and hydration
- I do not wish to receive artificial nutrition and hydration
Part IV: Signature
My signature affirms that I understand the contents of this document and the effect of the delegation of my health care decisions to my appointed Health Care Agent. I am mentally competent to make this Living Will, and I understand my right to revoke it at any time.
Signature: _______________________________ Date: _______________
Witness (1) Name: ____________________________________________
Witness (1) Signature: ____________________ Date: ______________
Witness (2) Name: ____________________________________________
Witness (2) Signature: ____________________ Date: ______________
Part V: Notarization (Optional)
This Living Will does not require notarization to be effective. However, if you choose to have it notarized, the notary must witness the signing of the document along with the witnesses.
Notary Public Signature: ______________________________________
Commission Expires: __________________________________________