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.