Declaration Provided By Colorado Medical Treatment Decision

Declaration provided by colorado medical treatment decision.

ACT, COLORADO STATUTES 15-18-104

DECLARATION AS TO MEDICAL OR SURGICAL TREATMENT

I Please state the name of the declarant, being of sound mind and at least eighteen years of age, direct that my life shall not be artificially prolonged under the circumstances set forth below and hereby declare that:

1. If at any time my attending physician and one other physician certify in writing that:

a. I have an injury, disease, or illness which is not curable or reversible and which, in their judgment, is a terminal condition; and

b. For a period of forty-eight consecutive hours or more, I have been unconscious, comatose, or otherwise incompetent so as to be unable to make or communicate responsive decisions concerning my person; then,

I direct that life-sustaining procedures shall be withdrawn and withheld, it being understood that life-sustaining procedures shall not include any medical procedure or intervention for nourishment or considered necessary by the attending physician to provide comfort or alleviate pain.

2. I execute this declaration, as my free and voluntary act,

this ___________________ day of _____________________, 19______.

By ___________________________________

Please state the name of the declarant, Declarant

The foregoing instrument was signed and declared by Please state the name of the declarant to be his declaration, in the presence of us, who, in his presence, in the presence of each other, and at his request have signed our names below as witnesses, and we declare that, at the time of the execution of this instrument, the declarant, according to our best knowledge and belief, was of sound mind and under no constraint or undue influence.

Dated at Please state the city where signed, Colorado, this ___________

day of _____________________________________, 19________.

________________________________________________________

Name and address

________________________________________________________

Name and address

STATE OF COLORADO

COUNTY of Please state the county where signed

Subscribed and sworn to before me by Please state the name of the declarant,

the declarant, and __________________________________, and

____________________________________, witnesses, as the voluntary

act and deed of the declarant, this ________________ day of

____________________ 19________.

________________________________________ Notary Public