Download a free template of an advance decision form
Use this template, created by Alzheimer's Society, to write an advance decision to refuse treatment.
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Advance decisions and advance statements
You can use our form to write down any specific treatments that you would not want to be given in the future, if you do not have mental capacity to refuse those treatments yourself at the time.
Read about dementia and advance decisions before you complete this form.
It is helpful to include as much detail as you can, so it is better to write down the circumstances in which you would not want to receive the treatment. This form will only be used if you do not have mental capacity to decide about having the specified treatment.
It cannot be used to refuse basic care, comfort and support. If you are refusing treatment which is, or could be, life-sustaining, you must state specifically that you are refusing it even if your life is at risk as a result.
Get your copy
Use our PDF template to write an advance decision. View the form and make sure you have saved a copy of it to your device before filling it out.