Advance Directive Form

An advance directive is a written document that allows you to put in writing what is most important to you regarding end-of-life care. An advance directive allows you to put in writing specifically what type of medical care you want and whom you want to facilitate your wishes.

If you decide to complete an advance directive, please print out the form, complete and submit to your Henry Ford physician. Your physician can also answer any additional questions you may have regarding this process.

Remember, an Advance Directive is only used by your Patient Advocate and the health care team when you are no longer able to speak for yourself. Until that time comes, you will make your own health care choices.

English: Advance Directive Form (PDF)

Arabic, العربية: Advance Directive Form (PDF)

Bengali, বাংলা: Advance Directive Form (PDF)

Spanish, Español: Advance Directive Form (PDF)

Schedule Appointment Online

** Check with your insurance carrier for coverage limitations.

If you can't find a date/time that works for you please call the provider’s office. Not all appointment types at all locations are available online.

Henry Ford Health System is committed to ensuring our Deaf or hard-of-hearing patients and visitors have equal access to all services. We provide the appropriate auxiliary aids and services, including qualified sign language interpreters, TTYs and other assistive listening devices, at no cost. To request assistance, call 313-916-1896 or email CommunicationAccess@hfhs.org.

Schedule Appointment for