Virginia Living Will Template
This Living Will is made under the laws of the Commonwealth of Virginia. It outlines your wishes regarding medical treatment in case you become unable to communicate those wishes yourself.
Personal Information
- Name: ______________________________________
- Date of Birth: ______________________________
- Address: ____________________________________
- City, State, Zip: ___________________________
Declaration
I, __________________________ (Your Name), being of sound mind, make this Living Will on this ________ day of ______________, 20____, for the purpose of ensuring that my wishes regarding medical treatment are known and honored.
Instructions
If I become terminally ill, are in a persistent vegetative state, or suffer from a condition deemed irreversible, I want the following:
- Life-sustaining treatment should be withheld or withdrawn if:
- My condition is terminal and I am unable to make decisions.
- I am in a persistent vegetative state.
- I wish to receive comfort care and pain relief, even if it may hasten my death.
- I do not want any treatments that would only prolong the dying process.
Appointing an Agent
If I am unable to make my own medical decisions, I appoint the following person to act on my behalf:
- Name of Agent: ________________________________
- Address of Agent: _____________________________
- Phone Number of Agent: ________________________
Signatures
This Living Will must be signed in the presence of two witnesses or a notary public. I understand that this document will be effective only when I am unable to make decisions about my medical treatment.
______________________________
Signature of Declarant
______________________________
Date
Witness 1: ________________________________
Address: ________________________________
Signature: ________________________________
Date: ___________________________________
Witness 2: ________________________________
Address: ________________________________
Signature: ________________________________
Date: ___________________________________
Notary Public
State of Virginia
County of ________________________________
Subscribed and sworn to before me on this ________ day of ______________, 20____.
______________________________
Notary Public
My commission expires: ______________________