Order ID : {{$livingWillForm['payment_order_id']}}

{{-- --}} {{-- --}} @if($livingWillForm['health_care_decisions'] == 'yes') @if($livingWillForm['proxy_authority'] != "Must follow my listed directions but is also able to make decisions not covered in this document") @endif @endif
Free Living Will
Field Value
ID: {{ $livingWillForm['id'] }}
Do you want to appoint someone to make your health care decisions if you are unable to? {{ $livingWillForm['health_care_decisions'] }}
Do you want to list your health care preferences so caregivers have instructions to follow? {{ $livingWillForm['preferences'] }}
Location
What state do you live in? {{ $livingWillForm['live_state'] }}
Care Choices
Care Choices: Sustaining Treatment @if($livingWillForm['sustaining_treatment'] == 'yes') I want to receive this treatment @else I do NOT want to receive this treatment @endif
Artificially Provided Food and Water @if($livingWillForm['artificially_food'] == 'yes') I want to receive this treatment @else I do NOT want to receive this treatment @endif
Care if Permanently Unconscious: Life Sustaining Treatment @if($livingWillForm['p_sustaining_treatment'] == 'yes') I want to receive this treatment @else I do NOT want to receive this treatment @endif
Care if Permanently Unconscious: Artificially Provided Food and Water @if($livingWillForm['p_artificially_food'] == 'yes') I want to receive this treatment @else I do NOT want to receive this treatment @endif
Your Info
Who is this Living Will being created for? @php $yourInfo = json_decode($livingWillForm['your_information'], true); @endphp
  • Name: {{ $yourInfo['name'] ?? 'Not specified' }}
  • Street Address1: {{ $yourInfo['street_1'] ?? 'Not specified' }}
  • Street Address2: {{ $yourInfo['street_2'] ?? 'Not specified' }}
  • State: {{ isset($yourInfo['state']) ? getState($yourInfo['state']) : 'Not specified' }}
  • City: {{ $yourInfo['city'] ?? 'Not specified' }}
  • Country: {{ isset($yourInfo['country']) ? getCountry($yourInfo['country']) : 'Not specified' }}
  • Zip Code: {{ $yourInfo['zip_code'] ?? 'Not specified' }}
  • Birthdate: {{ $yourInfo['bdate'] ?? 'Not specified' }}
  • Gender: {{ $yourInfo['gender'] ?? 'Not specified' }}
Proxy
If I need someone to speak for me @php $proxy = json_decode($livingWillForm['proxy'], true); @endphp
  • Proxy Name: {{ $proxy['proxy_name'] ?? 'Not specified' }}
  • Proxy Street: {{ $proxy['proxy_street'] ?? 'Not specified' }}
  • Proxy State: {{ isset($proxy['proxy_state']) ? getState($proxy['proxy_state']) : 'Not specified' }}
  • Proxy Town: {{ $proxy['proxy_town'] ?? 'Not specified' }}
  • Proxy Zip Code: {{ $proxy['proxy_zip_code'] ?? 'Not specified' }}
  • Proxy Relationship: {{ $proxy['proxy_relationship'] ?? 'Not specified' }}
Alternate Health Care Proxy @php $alternateProxy = json_decode($livingWillForm['alternate_proxy'], true); @endphp
  • Alternative Name: {{ $alternateProxy['alternative_name'] ?? 'Not specified' }}
  • Alternative Street: {{ $alternateProxy['alternative_street'] ?? 'Not specified' }}
  • Alternative State: {{ isset($alternateProxy['alternative_state']) ? getState($alternateProxy['alternative_state']) : 'Not specified' }}
  • Alternative Town: {{ $alternateProxy['alternative_town'] ?? 'Not specified' }}
  • Alternative Zip Code: {{ $alternateProxy['alternative_zip_code'] ?? 'Not specified' }}
  • Alternative Phone: {{ $alternateProxy['alternative_phone'] ?? 'Not specified' }}
  • Alternative Relationship: {{ $alternateProxy['alternative_relationship'] ?? 'Not specified' }}
How much authority do you want your health care proxy to have? {{ $livingWillForm['proxy_authority'] }}
Instructions for Health Care Proxy: Have access to my medical records @if(!empty($livingWillForm['medical_records'])) yes @else No @endif
Instructions for Health Care Proxy: Decide if I need tube feeding @if(!empty($livingWillForm['tube_feeding'])) Yes @else No @endif
Final Details
Contacts @php $contacts = json_decode($livingWillForm['contacts'], true); @endphp @if (is_array($contacts)) @foreach ($contacts as $contact)
  • Name: {{ $contact['full_name'] ?? 'Not specified' }}
  • Phone Number: {{ $contact['phone_number'] ?? 'Not specified' }}
@endforeach @else {{ 'No' }} @endif
Signing Details @php $signingDetails = json_decode($livingWillForm['signing_details'], true); @endphp
  • Signing: {{ $signingDetails['signing'] ?? 'Not specified' }}
  • Date: {{ $signingDetails['date'] ?? 'Not specified' }}
  • City: {{ $signingDetails['city'] ?? 'Not specified' }}
Created At: {{ isset($livingWillForm['created_at']) ? date('m/d/Y h:i A', strtotime($livingWillForm['created_at'])) : 'Not specified' }} (EST)
Updated At: {{ isset($livingWillForm['updated_at']) ? date('m/d/Y h:i A', strtotime($livingWillForm['updated_at'])) : 'Not specified' }} (EST)