Do you want to create documents for both of you? *

Yes

No

If YOU become terminally ill or injured: Do YOU want to have life sustaining treatment? Life sustaining treatment includes drugs, machines, or medical procedures that would keep you alive but would not cure you. *

Yes

No

If YOU become terminally ill or injured: Do YOU want to have food and water provided through a tube or an IV? *

Yes

No

Let my Healthcare Agent decide.

If YOU become permanently unconscious: Do YOU want to have life-sustaining treatment? *

Yes

No

If YOU become permanently unconscious: Do YOU want to have food and water provided through a tube or an IV? *

Yes

No

Healthcare Agent

If YOUR SPOUSE becomes terminally ill or injured: Does he or she want to have life sustaining treatment? Life sustaining treatment includes drugs, machines, or medical procedures that would keep him or her alive but would not cure him or her. *

Yes

No

If YOUR SPOUSE becomes terminally ill or injured: Does he or she want to have food and water provided through a tube or an IV? *

Yes

No

If YOUR SPOUSE becomes permanently unconscious: Does he or she want to have life-sustaining treatment? *

Yes

No

If YOUR SPOUSE becomes permanently unconscious: Does he or she want to have food and water provided through a tube or an IV? *

Yes

No

Your Phone Number *

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