Virginia Advance Health Care Directive(Living Will) Form

The Virginia advance health care directive(living will) is a legal document that a person (Principal) is able to complete, while they are aware and of sound mind. The document will allow the Principal to plan their medical care so that when they are coming to the end of their life, their health care providers and their health care agents, will have an ability to refer to the document, to be certain they are honoring the Principal’s wishes. If the Principal has not yet appointed a health care agent, they may do so on this form. The document must be witnesses to be effective. The Principal should understand that they may change or revoke this document as they wish.


Laws – 54.1-2981, et seq. Health Care Decision Act

How to Write

Step 1 – Download the document –

  • Enter the name of the Principal in the line at the top of the page
  • If someone else is preparing this document on behalf of the Principal, they must enter their full name (ie: Friend, attorney, advocate etc…)

Step 2 – Appointment of Agent –

  • If the Principal chooses to forego appointment of a health care agent, cross through this section entirely
  • If the Principal wishes to appoint an agent, provide the following:
  • Agent’s name
  • Email address
  • Home address
  • Telephone number
  • In the event the Primary agent is unable to serve for any reason, appoint a successor agent by providing the following:
  • Successor Agent’s name
  • Email address
  • Home address
  • Telephone number
  • Read the remaining paragraphs carefully
  • If, in fact, the Principal has appointed an agent, read through the Powers of Agent section and cross through any of these powers that the Principal chooses not to grant to their agent
  • The Principal must enter any special instructions regarding visitatiaon in the event the Principal is admitted to a health care facility
  • The Principal must enter any additional powers or limitations if any, at the end of this section, within the lines provided

Step 2 – Health Care Instructions –

  • In the event it is determined that the death of the Principal is imminent and all treatment options have been exhausted the principal must read the statements and check only one choice that would best reflect the Principals final decision under each statement
  • If there are other instructions, the Principal may enter their own instructions in the lines provided

Step 3 – Anatomical Gifts –

  • Should the Principal wish to participate in organ donation or whole body donation check the appropriate box
  • If the Principal would like to direct special instructions regarding the donation process, enter the the special instructions into the lines provided

Step 4 – Affirmation and Right to Revoke – Provide the following information:

  • Signature of Principal

Witness Signatures – The Witnesses must read the statement and provide the following:

  • Witnesses respective signatures
  • Witnesses printed or typed names

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