Valid Living Will Template for the State of Connecticut

Connecticut Living Will Template

This Living Will is designed to be compliant with the Connecticut Public Act No. 22-18, also known as the "Connecticut Living Will or Health Care Instructions Act." It serves as a directive for health care providers regarding the preferences for medical treatment of the undersigned, in the event they are unable to communicate their wishes themselves.

Please complete the following sections with your personal information and health care preferences. This document should be discussed with your health care provider and kept in a place where it can be easily accessed when needed. It is recommended to provide a copy to your appointed health care representative, if any.

Personal Information

Full Name: ___________________________

Date of Birth: ___________________________

Address: ___________________________

City: ___________________________

State: Connecticut

Zip Code: ___________________________

Telephone Number: ___________________________

Health Care Representative

If you have appointed a health care representative, provide their information below. If not, consider discussing with a trusted individual who is willing and able to take on this responsibility.

Name: ___________________________

Relationship: ___________________________

Telephone Number: ___________________________

Alternate Telephone Number: ___________________________

Living Will Instructions

Please indicate your preferences regarding life-sustaining treatment if you become terminally ill, are in a coma, or have a similar condition from which your health care provider believes there is no reasonable expectation of recovery.

• I wish to receive all available life-sustaining treatments, including respiration and cardiac support.
• I do not wish to receive the following treatments: __________________________________________________________.
• In the event I am unable to communicate my wishes, and I am in a terminal condition, I wish the following specific instructions to be followed: __________________________________________________________.

Signature

Date: ___________________________

I declare that this Living Will represents my wishes and I understand the consequences of these directives. I am mentally competent to make this Will and do so voluntarily.

Signature: ___________________________

Printed Name: ___________________________

Witness

This Living Will must be signed in the presence of two witnesses, who are not related to the principal by blood or marriage, and who are not beneficiaries of the principal's estate.

Witness 1 Signature: ___________________________

Printed Name: ___________________________

Date: ___________________________

Witness 2 Signature: ___________________________

Printed Name: ___________________________

Date: ___________________________