|
Connecticut Living Will Form (Advance Directive) |
The Connecticut Living Will / Health Care Instructions have been created to allow a patient to legally choose their medical treatment if they become incapacitated or irrational rendering them unable. This may be a coma, unconsciousness or mental impairment. The form requires two witnesses’ signatures, in accordance with § 19a-575a, § 19a-575.
How to Write
Living Will Health Care Instructions
- Enter name of principal.
Specific Instructions
Enter details stating to `Provide` or `Not Provide` specific health care instructions.
- Cardiopulmonary resuscitation.
- Artificial respiration.
- Artificial provision of nutrition / hydration.
- Other specific requests.
Specific Pain Medication
Enter principals details if pain medication is to be refused.
- Signature of Principal.
- Date.
Witness Statements
Enter principals name and details of witnesses.
- Principal`s name.
- Witnesses signatures.
- Witnesses addresses.
Witnesses Affidavits (Optional)
Enter affidavits details.
- Date.
- County.
- Town.
- Signatures.
- Addresses.
- Enter names.
- Re-enter date.
- Name of notary.
- Expiration date of notary.
