Advance Decision of ____________________
I, ____________________, of ____________________, ____________________, ____________________, England, being of sound mind and over the age of 18 years, make this Advance Decision fully understanding the consequences of my action in doing so. I intend this Advance Decision to be read by my health care providers, family and friends as a true reflection of my wishes and instructions should I become incapacitated and unable to communicate such wishes and instructions.
As used in this document:
I direct that my health care providers and others involved in my care provide, withhold or withdraw treatment in accordance with my directions below:
SIGNATURESigned at ____________________, ____________________, this 17th day of January, 2017.______________________________________________________________________________________________________________England____________________Birth date: 17 January 2017
STATEMENT OF WITNESSI declare that:
RECORD OF COPIESRecord of people and institutions to whom I have given a copy of this Advance Decision:
Instructions for executing your Advance Decision
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