Full Name:........................................................Hospital ID number ....................................

Address....................................................................................................................................

Passport Number ................................Country...............................Expiry date ........................

Being of sound mind and understanding all the implications, I ask that this document be brought to the attention of any medical facility in whose care I happen to be, and to any person who may become responsible for my affairs. This is my 'Living Will' stating my wishes in that my life should not be artificially prolonged, if this sacrifices my Quality of Life.
If, for any reason, I am diagnosed as being in a terminal condition, I wish that my treatment be designed to keep me comfortable and to relieve pain, and allow me to die as naturally as possible, with as much dignity as can be maintained under the circumstances.

As well as the situation in which I have been diagnosed as being in a terminal condition, these instructions will apply to situations of permanently unconscious states and irreversible brain damage.
In the case of a life-threatening condition, in which I am unconscious or otherwise unable to express my wishes, I hereby advise that I do not want to be kept alive on a life support system, nor do I authorize, or give my consent to procedures being carried out which would compromise any Quality of Life that I might expect in the future.
I ask that you are sensitive to and respectful of my wishes; and use the most appropriate measures that are consistent with my choices and encompass alleviation of pain and other physical symptoms; without attempting to prolong life.
Being of sound mind at the time of making this declaration, I ask that you will follow my wishes. It is my conviction that Quality of Life must be the main consideration for all decisions, not length of life.
In witness hereof, I have signed this document, which has also been signed by witnesses, who have read and understand my wishes.

Declared by (your signature)...................................................................

Signatures of witnesses ………………………………...............…… ...........................

and by .........................................................

Witnesses names – print using capital letters or type................................................,

and by .................................................................................................................

Date: ……………………………………… (Day/month/year – dd/mm/yyyy)

Phone number..........................Email address...........................................................

Footnote: refer to the Thai National health Act, Art. 12, Part 1, dated 20 March 2550.