Pledge To Stay In Touch
Living Will For The Missing
I, ______________________________________________, being of sound mind, make this statement as a directive to be followed if I become a missing person.
I realize my moral obligation to my family and the impact my absence will have upon their lives. It is not plan at any point in time to fall out of reasonable contact.
I realize that there are thousands of missing persons in the USA and swift action is the best way to prevent.
I realize that privacy issues, created to protect individuals, can sometimes stand in the way of the location of a valid missing persons case.
If I am absent from my normal routine in responsibilities of life, it is my wish that immediate action be taken to retrieve and return me to my loved ones.
I have provided: (Please check all that apply):
_____Dental information _____Fingerprints _____DNA Sample
For such action should it ever become necessary. I have also filled out a form with current photo (found on pages 3 and 4 of this document) that includes my physical description, true to the best of my ability, to be used in the event I should become a missing person.
I HEREBY APPOINT THE FOLLOWING AS MY GUARDIAN OF THIS INFORMATION:
Name:
Address:
Phone Number:
I attest the above mentioed is my representative and witness to the guidelines I have expressed in this document. I direct my agent to act in accordance with my wishes and instructions as stated above or as otherwise known to him or her. I also direct my agent to abide by any limitations on his or her authority as stated above or as otherwise known to him or her.
In the event my primary representative is unable, unwilling, or unavailable to serve as such, then I appoint as my substitute representative (with the same powers that I have heretofore enumerated).
Name:
Address:
Phone Number:
I understand that unless I revoke it, this directive will remain in effect indefinitely.
These directions express my legal right to refuse treatment, under current laws. Unless I have revoked this instrument or otherwise clearly and explicitly indicated that I have changed my mind, it is my unequivocal intent that my instructions as set forth in this document be faithfully carried out.
Signature:
Address:
Date:
Statement By Witnesses
(Must Be 18 or Older)
I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will . He or she signed this document in my presence.
Witness:
Address:
Witness:
Address:
PLACE
PHOTO
HERE
The above photo along with physical description below is current as of _________/________/________
Date of Birth:
Sex:
Race:
Height:
Weight:
Hair Color:
Eye Color:
Known Birth Defects (skeletal and/or organ):
Moles/Birthmarks:
Scars:
Tattoos:
Piercings:
Dental prothetics, implants or extractions:
Previous Surgeries:
Other known medical conditions:
Physician/Surgeon (Name and location, who would have most recent medical history):
Dentist (Name and location, who would have most recent dental records):
Basic Dental Report
UPPER 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 UPPER
RIGHT __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ RIGHT
LOWER 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 LOWER
LEFT __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ LEFT
N = Natural tooth, no filling
F = Filling
C = Crown or Cap
B = Part of a Bridge
A = Antemortem loss (headed socket)
I = Impacted
O = Other features (i.e., root canal)
Dental Summary (Check all that apply)
_____ Baby/Primary Teeth Present
_____ Upper Jaw Has No Teeth
_____ Lower Jaw Has No Teeth
_____ Restorations / Filings / Crowns
_____ Root Canal
_____ Braces
_____ Retainer
_____ Removable Dentures
_____ Cemented Bridge
_____ Implants
Dental Comments:
