Illinois Living Will
This Living Will is created in accordance with the Illinois Living Will Act (755 ILCS 35). By signing this document, I express my wishes regarding medical care in the event that I become unable to communicate my preferences.
Personal Information:
- Full Name: ___________________________
- Date of Birth: _______________________
- Address: ____________________________
- City, State, Zip: __________________
- Phone Number: _____________________
Designated Agent:
I designate the following person as my healthcare agent. This individual is authorized to make medical decisions on my behalf if I am unable to do so:
- Name of Agent: _________________________
- Address: ____________________________
- Phone Number: _____________________
Wishes Regarding Medical Treatment:
If I become terminally ill or permanently unconscious, I wish to make my healthcare preferences clear:
- I do not wish to receive life-sustaining treatment if:
- I have an incurable or irreversible condition, and I am expected to die within a short time without such treatment.
- I am in a state of permanent unconsciousness, and there is no reasonable chance of recovery.
- I do wish to receive relief from pain and other discomforts, even if it may inadvertently hasten my death.
- Other specific requests:
- __________________________________________________
- __________________________________________________
Signatures:
By signing below, I affirm that this Living Will reflects my wishes regarding medical treatment:
- Your Signature: ____________________________
- Date: _________________________________
Witness Statement:
In the presence of the person who signed this Living Will, I declare that I am at least 18 years of age, and I am not the named agent or a person entitled to any portion of the estate of the individual:
- Witness Signature: ____________________________
- Print Name: _______________________________
- Date: ___________________________________
This Living Will shall remain in effect until revoked by me in writing.