North Carolina Living Will
This Living Will is made pursuant to the laws of the State of North Carolina, specifically referencing the North Carolina General Statutes § 90-320 et seq. It serves to indicate your wishes regarding medical treatment in the event you become unable to communicate your preferences.
Personal Information:
- Full Name: ______________________________
- Date of Birth: ______________________________
- Address: ______________________________
- City, State, Zip: ______________________________
- Phone Number: ______________________________
Designation of Health Care Agent:
I appoint the following individual as my Health Care Agent to make health care decisions on my behalf if I am unable to do so:
- Name: ______________________________
- Address: ______________________________
- Phone Number: ______________________________
Instructions Regarding Medical Treatment:
In accordance with my wishes, I provide the following instructions concerning my medical care:
- If I am in a terminal condition or a persistent vegetative state, I do not wish for life-prolonging measures to be used.
- If I am unable to communicate, I desire to receive comfort care and pain relief.
- Other specific wishes: _______________________________________________
This Living Will revokes all prior Living Wills made by me.
Signatures:
Signed: ______________________________
Date: ______________________________
Witnesses: This document must be signed in the presence of two witnesses who are not related to me and will not inherit from me:
- Witness 1: ______________________________
- Witness 2: ______________________________