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Advance Directive – Document Builder 👷‍♂️

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– Step 1 of 8

🌍 Jurisdiction & Basics

Country, language, governing region, and document basics.

Country *

State *

City/Area *

Language of the completed document *

Document Effective Date *

Include Durable Health Care Power of Attorney? *

Yes
No

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👤 Principal & Agents

Your details and the health‑care agent(s) who can decide for you.

Principal — Full Legal Name *

Principal — Date of Birth

Principal — Address *

Primary Agent — Full Name *

Primary Agent — Phone/Email

Alternate Agent — Full Name (optional)

Alternate Agent — Phone/Email (optional)

Agent Authority Limits / Exclusions (optional)

HIPAA Authorization (allow agent to access medical records)

Yes
No

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🩺 Treatment Preferences

Life support, CPR, tube feeding, and pain management.

Life‑Sustaining Treatment *

Resuscitation Preference *

Tube Feeding / Hydration *

Pain Management *

Additional directives for treatment (optional)

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⚖️ End‑of‑Life & Special Situations

Terminal condition, permanent unconsciousness, pregnancy, and religious beliefs.

If terminal or permanently unconscious

Decline life‑sustaining treatment (comfort only)
Receive life‑sustaining treatment
Follow agent’s decision at time

Pregnancy considerations (if applicable)

Maintain life support to sustain pregnancy if possible
Follow my stated preferences regardless of pregnancy

Religious / moral beliefs impacting care (optional)

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🧠 Organ Donation & Mental Health

Organ donation and psychiatric treatment preferences.

Organ/Tissue Donation *

Specific organs/tissues to donate (if selected)

Psychiatric / Mental Health Preferences *

Mental health directive details (if included)

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📬 Access, Notices & Disputes

Who gets copies, formal notice addresses, and dispute handling.

People to receive copies (names/emails)

Notice Addresses (for formal notices) *

Dispute Resolution (if needed) *

Venue / Seat / Rules (if arbitration)

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🖋️ Witnesses / Notary

Witness and/or notary details as required by jurisdiction.

Execution Method *

Two witnesses
Notary public
Two witnesses + Notary

Witness 1 — Name & Address

Witness 2 — Name & Address (if applicable)

Notary — Name & Commission (if applicable)

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✍️ Signatures & Attachments

Acknowledgements, signatures, and uploads.

Acknowledgements (must check all) *

Information provided is true and correct
I understand these directives guide my healthcare
Electronic signatures valid where permitted

Principal Signature (type name) *

Principal Sign Date *

Agent Signature (type name) (optional)

Agent Sign Date (optional)

Attachments (IDs, prior directives, physician notes)

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Save and Resume Later

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

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Email *

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