Living Will of ___________________

I, ________________ OF, _________________________________being of sound mind, do hereby declare that this is my Living Will and I voluntarily make this declaration. I intend this declaration to be honored as the expression of my legal right to authorize or refuse medical treatment. My desires concerning medical treatment are: If all of the following conditions are met: 1. I become terminally ill or permanently unconscious as determined by my personal physician ______________________________________________ and at least one other physician; 2. (Put other instructions/conditions here) 3. ________________________________________________________

4. ________________________________________________________ I direct my healthcare providers to refrain from any treatment that involves artificial nutrition or artificial hydration. However, I do want maximum pain relief even if this might hasten my death. I appoint ____________________________________ to be my health care agent with full power of attorney to make health care decisions based on this document and any views I may have previously expressed. In situations where my wishes are unknown, I instruct my health care agent to make decisions based on what he considers to be in my best interest and in keeping with my own personal values. My family, the medical facility, and all doctors, nurses and other medical personnel involved in my care shall have no civil or criminal liability for following my wishes as expressed in this declaration. I may change my mind at any time by communicating in any manner that this declaration does not reflect my wishes. I sign this document this _____ day of _______________ at ________________ after careful consideration and full understanding of its meaning and consequences.

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SIGNED IN THE PRESENCE OF:

____________________________

_____________________________

ACKOWLEDGEMENT REPUBLIC OF THE PHILIPPINES) _____________ ) BEFORE ME, this _____ day of __________, 20__, in ________________, Philippines, personally appeared the following persons together with their respective witnesses, showing to me their competent evidence of identity:

known to me to be the same persons who executed the foregoing LIVING WILL, consisting of two (2) pages including this page upon which this acknowledgement is written, and they acknowledged to me that the same is their free act and deed. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notarial seal, the day, year and place above written. NOTARY PUBLIC Doc. No. ______ Page No. ______ Book No. ______ Series of 20__

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