Alabama Advance Directive for Health Care

Section I - Living Will

I, _______________________________ with a mailing address of ______________
____________________________________________________________________,
being of sound mind, memory, disposition, understanding, and at least eighteen years
of age, do willfully and intentionally, by this Living Will, direct my family,
physician(s), attorney, and any other individuals who may become responsible for my
health and well-being in the future, whether partly or fully, to take the following
actions in each of the circumstances described in the Living Will below.

1. In the event that I develop a condition considered “terminal” with my attending

physician and one other medical professional both agreeing that there is no
chance for improvement, I request the following:

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

2. In the event that I fall into a coma with my attending physician and one other
medical professional both agreeing that there is no chance for recovery, I direct
the following:

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

3. In the event that I develop a persistent vegetative state with my attending

physician and one other medical professional both determining that there is no
chance for recovery, I request the following:

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
 _______________________________________________________________
_______________________________________________________________
_______________________________________________________________

4. In addition to the directions I have listed above, I also request the following:

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Section II - Health Care Proxy

I would like to appoint __________________________________ with a mailing

address of ____________________________________________________________,
to act as my Health Care Proxy. I have talked with this person about my wishes.

They can be reached at ______________________________ during daytime hours or

at ______________________________​​ at night.

If this person is not able or not willing to serve as my Health Care Proxy, I would like
to appoint __________________________________ with a mailing address of
____________________________________________________________, to act as
my Health Care Proxy. I have talked with this person about my wishes.

They can be reached at ______________________________ during daytime hours or

at ______________________________​​ at night.

I want my Health Care Proxy:

❏ to follow only the directions as listed on this form.

❏ to follow my directions as listed on this form and to make any decisions about
things I have not covered in the form.

❏ to make the final decision, even though it could mean doing something
different from what I have listed on this form.
 Section III - Acknowledgement

I understand the following:

● If my doctor or hospital refuse to follow the directions I have listed, they must
see that I get to a doctor or hospital who will follow my wishes.

● If I am pregnant, or if I become pregnant, the choices I have made on this form

will not be followed until after the birth of the child.

● If the time comes for me to stop receiving life-sustaining treatment or food and
water through a tube or an IV, I direct that my doctor talks about the good and
bad points of doing this, along with my wishes, with my health care proxy, if I
have one.

Section IV - Signatures
Principal

By signing this Advance Directive in front of the witnesses identified below, I hereby
administer and subscribe to the declarations made above both freely and voluntarily,
and wholeheartedly request that my family, physician(s), attorney, and any other
individuals who may in the future become responsible for my health and well-being,
whether partly or fully, all abide by my wishes as stated herein.

_________________________________
Name
_________________________________
Signature
_________________________________
Date of signing
 Witnesses

This Advance Directive was signed by _________________________________ in the

presence of the following two witnesses, who by their signatures below, confirm that
_________________________________ was, at the time this document was signed,
at least eighteen years of age, of sound mind, memory, disposition, understanding, not
under any improper influence and able to understand the weight of this decision. The
undersigned have subscribed this document in the presence of each other and
_________________________________ and at their request.

First Witness: ​
_________________________________ ​
with a mailing address of
____________________________________________________________________.

_________________________________
Signature
_________________________________
Date of signing

Second Witness: ​
_________________________________ ​
with a mailing address of
____________________________________________________________________.

_________________________________
Signature
_________________________________
Date of signing

Health Care Proxy

I, _________________________________, am willing to serve as the health care

proxy.

_________________________________
Signature

_________________________________
Date of signing
I, _________________________________, am willing to serve as the health care
proxy if the other health care proxy will be unable to serve.

_________________________________
Signature

_________________________________
Date of signing

Notary Acknowledgement

STATE OF ALABAMA
COUNTY OF _________________________________

I, _________________________________, a Notary Public of said County, do certify

that _________________________________, as Principal, and __________________
________________ and _________________________________, as witnesses,
whose names are signed to the writing above bearing date on the _______ day of
______________, ______, have this day acknowledged the same before me.

Given under my hand this _______ day of ______________, ______.

My commission expires: ___________________________________

______________________________________
Signature of Notary Public