Download Free Advance Directive Template for Summit County, Ohio

ADVANCE DIRECTIVE FOR HEALTHCARE
State of Ohio

PART I — APPOINTMENT OF HEALTHCARE AGENT

I, [YOUR NAME], of [ADDRESS], Ohio OH, appoint the following person as my Healthcare Agent:

Agent Name: [AGENT NAME]
Address: [AGENT ADDRESS]
Phone: [PHONE]

Alternate Agent: [ALTERNATE NAME]
Address: [ALTERNATE ADDRESS]
Phone: [PHONE]

My Healthcare Agent is authorized to make all healthcare decisions for me when I am unable to do so, including decisions about life-sustaining treatment.

PART II — INSTRUCTIONS FOR HEALTHCARE

If I am terminally ill or permanently unconscious:
[  ] I DO want life-sustaining treatment
[  ] I DO NOT want life-sustaining treatment
[  ] I want treatment only if my doctor believes it will improve my condition

Artificial Nutrition and Hydration:
[  ] I DO want artificial nutrition and hydration
[  ] I DO NOT want artificial nutrition and hydration

Pain Management:
I want all measures taken to keep me comfortable and free from pain, even if such measures hasten my death.

Organ Donation:
[  ] I wish to donate my organs and tissues
[  ] I do not wish to donate my organs

PART III — GENERAL PROVISIONS
This directive is made in accordance with Ohio law (OH Statutes). It shall remain in effect until revoked.

DECLARANT SIGNATURE: _____________________ DATE: _____

WITNESS 1: _____________________ DATE: _____
WITNESS 2: _____________________ DATE: _____

NOTARY (if required in Ohio):
Subscribed and sworn before me this ___ day of _______, 20__.
Notary Public: _____________________