Wishes Beyond Life - My Living Will Print
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My Wishes Beyond Life
Living Will - Advance Decision
My Details
Wishes Beyond Life URN: Name: Sex: Date of Birth: Address: 3833601225706437 Mrs Martha Test Female 10 January 1950 123 Black Drive Pitts Estate Manchester M24 1XY GB Telephone: Mobile Phone: Email Address: NHS Number: National Insurance Number: Distinguishing Features: 0161 213 4321 07221133456 martha@virginmedia.co.uk 9876543211 AB 23 23 23 Z Type any distinguishing features here
My Advance Decision
This Living Will is made on the 17th of November 2008 I, Mrs Martha Test, of 123 Black Drive, Pitts Estate, Manchester, M24 1XY, GB, born on 10 January 1950, being of sound mind make this Advance Decision for my medical care and treatment directed to my family, friends, doctors and any other medical personnel or institution. If my doctor/specialist and one other independent medical practitioner certify in writing that in their opinion: I have a terminal, incurable or irreversible injury, disease or illness or I am permanently unconscious, comatose, in a persistent vegetative state with no reasonable chance of recovery and I am no longer able to make decisions regarding my medical treatment
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Wishes Beyond Life - My Living Will Print
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then my Advance Decision regarding the following treatments is as follows: Cardio Pulmonary Resuscitation: Artificial ventilation: Artificial Nutrition and Hydration: Intubation: Dialysis: Blood transfusion: Antibiotics: In the event that should I be pregnant at the time of suffering from one of the above conditions: regarding receiving such medical procedures that will prolong my life or keep me alive by artificial means until such time as my child has been born: The above are my wishes and my "Advance Decision" and my wishes stand EVEN IF LIFE IS AT RISK: I have read and understood the guidance on Living Will: Undecided Undecided Undecided Undecided Undecided Undecided Undecided I am Undecided
I Agree
Yes
Signatures
This document records the final wishes of the client regarding their intentions following death. This supersedes any other documents relating to wishes after death preceding the date of this document. The client provides consent for information in this document to be shared with public organisations (Hospitals, GP, Social Services, Police) or next of kin following death to allow the client's wishes to be fulfilled. Maker of Advance Decision: Client Signature:
Client Signature Date:
Witness Signature:
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Witness Name:
Witness Address:
Witness Signature Date: Post to: Wishes Beyond Life, 133-135 Manchester Old Road, Middleton, Manchester, M24 4DZ, UK
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17/11/2008