LIVING WILL
    I, First Name (required) Family Name (required) , being of sound mind, do hereby willfully and voluntarily make known my desire that when I am terminally ill, a condition as diagnosed by my physician, I request physicians, nurses, and staff of the Be Well Medical Center, and of any other certified medical institute in Thailand where I will be admitted, treated or referred to, not to provide any medical care that would only serve either to artificially delay the moment of my death or to prolong the suffering from my illness.

    I wish to decline the following life-sustaining treatments
    Signature of Patient

    Cardiopulmonary Resuscitation

    Tracheal Intubation

    Artificial Ventilation

    Intravenous Fluid

    Parenteral Nutrition

    Circulatory support using medications or medical equipment

    Care in Intensive Care Unit (ICU)

    Hemodialysis in case of renal failure

    Others, please specify:

    All physicians, nurses, other healthcare providers who have executed my intention as stated in this Living Will are deemed not legally responsible and released from all liabilities. I read and understood the conditions and regulations of the Living Will as attached herein.
    PATIENT DETAILS
    First Name (Required):
    Family Name (Required):
    Nationality (Required):
    Pasport No (Required):
    Phone No (Required):

    Address (Required):
    PATIENT DECLARATION
    I hereby certify that I am competent and fully conscious while filling out this document. I have read and clearly understood that this Living Will is in accordance with my wishes. I therefore sign my name in the presence of witnesses.

    Signature:

    Date:

    Kantee Isareenuruk
    License Number
    Stamp of Notary Public

    Signature:

    Date:

    Witness Name:

    Signature:

    Date:

    Please state if spouse or relative of patient | Relationship:

    DECLARATION BY PHYSICIAN
    I, Dr......................................................................................., License: .......................... , do hereby certify that the patient, ..................................................................................., is fully conscious while completing this Living Will

    Signature:

    Date: