Seatons Solicitors (01536) 201214 - Living Will Questionnaire

LIVING WILLS QUESTIONNAIRE

Please provide your contact information:

Full Name
Full Address
Home Phone
Work Phone
Mobile Phone
FAX
E-mail
Have you discussed this with your Doctor	Yes No
Doctor's Name and Address

Physical Illness

If you should suffer from physical illness from which there is no likelihood of recovery, and is so serious that your life is nearing its end :-

a.	Do you wish to be kept alive for as long as reasonably possible, using whatever form of medical treatment is available ?
Or
b.	Do you not wish to be kept alive by medical treatment, but wish medical treatment to be limited to keeping you comfortable and free from pain ?

Mental Impairment

If you should suffer from a permanent mental impairment which is so severe that you do not understand what is happening to you :-

a.	Do you wish to be kept alive for as long as reasonably possible, using whatever form of medical treatment is available ?
Or
b.	Do you not wish to be kept alive by medical treatment, but wish medical treatment to be limited to keeping you comfortable and free from pain ?

Permanent Unconsciousness

If you should become permanently unconscious, with no likelihood of regaining consciousness :-

a.	Do you wish to be kept alive for as long as reasonably possible, using whatever form of medical treatment is available ?
Or
b.	Do you not wish to be kept alive by medical treatment, but wish medical treatment to be limited to keeping you comfortable and free from pain ?

Specific Wishes

Yes No	Do you wish to express any wishes about specific medical treatment or investigations that you may in the future require ?
If "Yes" please provide details
Yes No	Would you like a particular person to be contacted or be given the chance to be with you before you die ?
If "Yes" please provide their Name and Address
Relationship
Home Phone
Work Phone
Mobile Phone

Health Care Proxy

Who do you wish to appoint to make decisions on your behalf about your medical treatment ?

Our fee for providing a Living Will is £30 including VAT. Please send a cheque for £30 payable to "SEATONS SOLICITORS" to

1 Alexandra Road
Corby
Northants
NN17 1PE

We will send you your Living Will Deed within 7 days.